Anaesthesia, 2006, 61, pages 505517 Correspondence . ....................................................................................................................................................................................................................

improve outcome after out-of-hospital cardiac arrest [1]. Sodium bicarbonate is not routinely recommended in the new UK Resuscitation Council guidelines [2]. This case provides an argument against discarding it completely. Although there are case reports of survival despite high blood lactate levels and a very low pH [35], most studies show a correlation between morbidity and mortality and plasma lactate. The present case illustrates the point that no biochemical test can absolutely predict patient outcome and that it is important not to underestimate the extremes of physiology the human body can tolerate.
J. D. V. Ryan James Cook University Hospital Middlesbrough TS4 3BW, UK E-mail: jamesryan@doctors.org.uk

References
1 Bar-Joseph G, Abramson NS, Kelsey SF, Mashiach T, Craig MT, Safar P, Brain Resuscitation Clinical Trial III, (BRCT III) Study Group. Improved resuscitation outcome in emergency medical systems with increased usage of sodium bicarbonate during cardiopulmonary resuscitation. Acta Anaesthesiologica Scandinavica 2005; 49: 615. 2 The UK Resuscitation Council. http:// www.resus.org.uk/pages/als.pdf. [accessed 8 December 2005]. 3 Lien D, Mader TJ. Survival from profound alcohol- related lactic acidosis. Journal of Emergency Medicine 1999; 17: 8416. 4 Ahmad S, Beckett M. Recovery from pH 6.38: lactic acidosis complicated by hypothermia. Emergency Medicine Journal 2002; 19: 16971. 5 Willcox N, Oakley P. Survival after an arterial pH of 6.57 following major trauma with exsanguinating haemorrhage associated with traumatic amputation. Resuscitation 2002; 53: 21721.

Awake intubation through the CTrach in the presence of an unstable cervical spine

In patients with an unstable cervical spine, it is recommended that induction

of anaesthesia should take place after (awake) intubation and neurological examination at the end of positioning [1]. The intubating laryngeal mask airway (LMA FastrachTM, The Laryngeal Mask Company Ltd, Wooburn Green, UK) has been shown to be effective in securing the airway, even when the neck is protected by in-line stabilisation [2]. The LMA CTrachTM (The Laryngeal Mask Company Ltd) is a modied intubating laryngeal mask airway, with an integrated breoptic system immediately in front of the aperture of the mask. A 3.5 inch (9 cm) LCD screen provides a breoptic view of the glottis during ventilation and intubation via this device. The video system is located below the epiglottis elevation bar. We report the successful use of the CTrach in three patients (one female, two male, ages 4155 years) with an unstable cervical spine. Following application of basic monitoring, supplemental oxygen via nasal cannula and a dexmedetomidine infusion were started. When the patients reached a Ramsay Sedation Scale score of 2, oropharyngeal topical anaesthesia with lidocaine spray 10% was applied. After 2 min, a size 4 LMA CTrach lubricated with lidocaine jelly 2% was inserted, the cuff inated with 30 ml of air, and a breathing circuit connected to allow the patient to breath oxygen 100%. The CTrach viewer was attached and a clear image of glottis was obtained. Lidocaine 2% 3 ml was administered through CTrach to the glottis and upper trachea and 2 min later a well lubricated 7.5 or 8 mm reinforced, cuffed tracheal tube was introduced through the vocal cords under direct vision for female and male patients, respectively. Correct tracheal tube placement was conrmed by capnography wave form and the dexmedetomidine infusion was stopped. Following a brief neurological examination the patients were positioned for surgery, another neurological examination performed, and anaesthesia induced. The time required for successful CTrach insertion and intubation, the quality of the quality of vision (ranked from 1 worse vision to 4 best vision) and the need to adjust the

Table 1 Insertion and intubation times and visual quality in all three cases intubated with the guide of LMA CTrachTM.
Case 1 Insertion time; s* Intubation time; s Quality of vision Necessity for manipulation 21 25 3 + Case 2 17 19 4 Case 3 15 21 4

*Time from picking up the CTrach to conrmation of capnograph trace.

CTrach were recorded (see Table 1). There were no complications observed. No single, best technique has been identied for these patients. Blind nasal intubation is successful in more than 90% of patients, but it requires multiple attempts in 6790% [3]. Fibreoptic laryngoscope assisted intubation seems ideal in these patients because neck mobilisation and wide mouth opening are unnecessary [4]. It requires, however, expensive, fragile equipment and there is a signicant learning curve necessitating repeated practice in normal patients. Ventilation and intubation through an intubating laryngeal mask airway has been used in the management of the difcult airway and unstable cervical spine [5, 6]. Although high success rates can be achieved with a blind technique through this, several attempts may be required and the incidence of oesophageal intubation can be up to 5% [7]. Intubation under direct vision through the intubating laryngeal mask airway using a breoptic laryngoscope has advantages. The rst attempt and overall success rates are higher than blind techniques [5, 8]. One of the major advantages of the image path of the CTrach is that manipulations of the device are more intuitive than those required to orientate the tip of conventional breoptic devices. Furthermore, the larynx is automatically sealed within the bowl of the mask as soon as the glottis is located, permitting good ventilation before intubation is attempted. As with the intubating laryngeal mask airway, the CTrach cannot be used easily in patients with restricted mouth

2006 The Association of Anaesthetists of Great Britain and Ireland

513

Correspondence Anaesthesia, 2006, 61, pages 505517 . ....................................................................................................................................................................................................................

opening. None of our patients had a mouth opening distance of less than 2.5 cm, even with an appropriately sized cervical collar in place. We believe that in patients with an unstable cervical spine who require awake intubation the LMA CTrach can be used safely and effectively. It is cheaper and can be obtained more easily than a breoptic laryngoscope, and does not require extensive experience to use successfully.
H. Bilgin lmaz C. Yy Uludag Universitesi Tip Fakultesi 16059 Bursa, Turkey E-mail: hbilgin@uludag.edu.tr

intubating laryngeal mas airway. Anaesthesia 2002; 57: 12832. Anaesthesia in patient with Hailey-Hailey disease

References
1 Crosby ET, Lui A. The adult cervical spine: implications for airway management. Canadian Journal of Anesthesia 1990; 37: 7793. 2 Asai T, Murao K, Tsutsumi T, Shingu K. Ease of tracheal intubation through the intubating laryngeal mask during manual in-line head and neck stabilisation. Anaesthesia 2000; 55: 825. 3 Oyegunle AO. The use of propanidid for blind nasotracheal intubation. British Journal of Anaesthesia 1975; 47: 37981. 4 Saha AK, Higgins M, Walker G, Badr A, Berman L. Comparison of awake endotracheal intubation in patients with cervical spine disease: the lighted intubating stylet versus the fiberoptic bronchoscope. Anesthesia and Analgesia 1998; 87: 4779. 5 Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A. Use of the intubating LMA-Fastrach in 254 patients with difficult-to-manage airways. Anesthesiology 2001; 95: 117581. 6 Asai T, Shingu K. Tracheal intubation through the intubating laryngeal mask in patients with unstable necks. Acta Anaesthesiologica Scandinavica 2001; 45: 81822. 7 Dimitriou V, Voyagis GS. Blind intubation via the ILMA: what about accidental oesophageal intubation? British Journal of Anaesthesia 1999; 82: 4789. 8 Pandit JJ, MacLachlan K, Dravid RM, Popat MT. Comparison of times to achieve tracheal intubation with three techniques using the laryngeal mask or
514

I would like to report the anaesthetic management of a patient with HaileyHailey disease. A 26-year-old female patient was scheduled for bilateral breast reduction surgery. She had HaileyHailey disease (benign familial pemphigus) and reported that the exacerbating factors for her were sweating, heat and friction. She had severe localised lesions in the axilla, groin and submammary folds. The patient decided to undergo bilateral breast reduction surgery because of persistent infected lesions in the submammary folds. She was using clobestasol propionate ointment topically for her disease. She was concerned about an exacerbation of her disease during the procedure. She applied the steroid ointment to all the affected and vulnerable areas and was kept warm (normothermic) on the ward. We aimed to avoid the triggering factors such as friction, heat and sweating or wet skin [1, 2]. The patient positioned herself on the operating table before induction of anaesthesia. With a propofol and remifentanil TIVA technique, a laryngeal mask airway was used to maintain the airway. She received antibiotic prophylaxis guided by the microbiology results of a swab of an affected area. All pressure areas were padded to avoid any friction. Her temperature was maintained between 35.7 and 36.1 C. The patient was given paracetamol, a non-steroidal anti-inammatory and morphine PCA. She had an uneventful peri-operative period and recovered without an exacerbation of her disease. Hailey-Hailey disease is a familial benign pemphigus rst described in 1939 by the Hailey brothers. The defect responsible has been identied on chromosome 3q2124. An abnormality of the protein SPCA1 (secretory pathway calcium manganese-ATPase), a calcium and manganese pump, leads to inadequate adhesion between skin cells (keratocytes) [13]. Hailey-Hailey disease is usually diagnosed on the basis of

its appearance and a family history. It can be mistaken for impetigo, thrush, tinea and other blistering conditions [1, 2]. There is no cure for Hailey-Hailey disease, but avoiding triggering factors such as sunburn, heating and friction helps to control the disease process [2]. Steroid creams, antibiotic creams, antiviral medication, phototherapy, lasers [4], botulinum toxin injections [5] and surgery have all been used. For the vast majority of patients the disease is a nuisance rather than a serious problem.
A. Shah Guys & St. Thomas Hospital London SE1 9RT, UK E-mail: akshatshah@hotmail.com

References
1 Lamb S. Hailey-Hailey disease. http://www.dermnetnz.org/systemic/ familial-pemphigus.html [accessed 19 October 2005]. 2 Helm TN, Lee TC. Familial benign pemphigus (Hailey-Hailey disease). http://www.emedicine.com/derm/ topic150.htm [accessed 19 October 2005]. 3 Haftek M, Kowalewski C, Mesnil M, Blaszczyk M, Schmitt D. Internalization of gap junctions in benign familial pemphigus (Hailey-Hailey disease) and keratosis follicularis (Dariers disease). British Journal of Dermatology 1999; 141: 22430. 4 Christian MM, Moy RL. Treatment of Hailey-Hailey disease (or benign familial pemphigus) using short pulsed and short dwell time carbon dioxide lasers. Dermatologic Surgery 1999; 25: 6613. 5 Lapiere JC, Hirsh A, Gordon KB, Cook B, Montalvo A, Klein AW. Botulinum toxin type A for the treatment of axillary Hailey-Hailey disease. Dermatologic Surgery 2000; 26: 3714.

Stridor: remember the oesophagus

A previously healthy 12-month-old boy (9.9 kg) had a choking episode with coughing whilst eating at nursery. Following this he was reluctant to take uids for 34 days and food for 7 days.

2006 The Association of Anaesthetists of Great Britain and Ireland