The LMA ProSeal

The LMA ProSeal is a reusable supraglottic airway device that incorporates a gastric drainage tube placed lateral to the main airway tube and which ends at the tip of the mask [12]. The gastric drainage tube is designed to separate the gastrointestinal and respiratory tracts, allowing regurgitated fluid to pass up the drain tube and bypass the glottis, thereby protecting the airway from soiling in the event of passive regurgitation. An important additional design feature is that a second, dorsally-located, cuff helps improve the airway seal, a particularly useful feature when positive pressure ventilation is desired. These design features were intended to achieve a better seal than an ordinary LMA permits, allowing patient ventilation using higher-than-usual airway pressures, as well as to reduce the likelihood of aspiration (because of the gastric drain tube). Figure 3 illustrates the device, while Figure 4 shows its correct anatomical positioning. A disposable (single-use) version of the LMA ProSeal, known as the LMA Supreme, should be also be available for commercial release as various national regulatory hurdles are addressed. Besides expanding use of the LMA into clinical scenarios where the conventional LMA might be relatively contraindicated (e.g., obese patients), there have been several reports where the LMA ProSeal has extricated patients from cannot intubate /cannot ventilate patients, where the LMA Fastrach and fiberoptic bronchoscope (FOB) were unsuccessful [13].

Figure 3. LMA ProSeal. In this illustration the term "Rear Boot" refers to the dorsal (posterior) cuff described in this article. Image credit: http://www.sebac.fr/

Figure 4. Illustration of the ProSeal LMA when correctly seated. Image credit: Keller C, Brimacombe J, Kleinsasser A, Loekinger A. Does the ProSeal laryngeal mask airway prevent aspiration of regurgitated fluid? Anesth Analg 2000; 91: 101720 Insertion of the ProSealTM LMA should be carried out following one of the manufacturers three recommended insertion techniques:

Insertion using a special metal introducer instrument Insertion using an index finger Insertion using a thumb

Illustrated instructions for all three techniques are available online at http://www.lmana.com/education-center/insertion-techniques.php In addition, video materials to help with training are available from the manufacturer. At least three malpositions for the ProSealTM LMA are known to occur: 1) insertion at an insufficient depth, 2) insertion into the glottis, and 3) ProSealTM LMA tip folded backwards behind the bowl against the posterior pharyngeal wall. Entry near or into the glottis may be quickly recognized as follows: after insertion of the unit and cuff inflation one places a dab of lidocaine gel or surgical lubricant at the end of the drainage port; with correct placement of the ProSealTM LMA the gel should not bulge in and out with ventilation. Brimacombe and Keller have developed a proposed algorithm for the management of airway obstruction when using the ProSeal LMA [14]. It has been reported that the LMA ProSeal is somewhat more difficult to insert than a conventional LMA, with a first pass success rates of 82% vs 91% respectively [15]; this has motived some Individuals to study alternative insertion methods. For instance, Brimacombe et al. reported that using a Gum Elastic Bougie (GEB)/laryngoscope guided insertion technique

produced a 100% first attempt success rate [16]. In a similar vein, Martinez-Pons and Madrid reported a 100% success rate by preloading the LMA ProSeal with an orogastric tube [17]. As noted earlier, the ProSeal LMA has helped expand supraglottic airway technology into clinical scenarios where the conventional LMA might be relatively contraindicated, such as obese patients, patients with gastroesophageal reflux, patients undergoing positive pressure ventilation or patients undergoing laparoscopic procedures. This "paradigm shift" has been discussed by Cook et al [18] and is illustrated in Figure 5.

Figure 5. Cook, Lee and Nolans proposal for modern airway management. Boxes represent use of the airway. represents variation in individual practice or margin of disagreement. Image Credit: T. M. Cook, G. Lee, and J. P. Nolan. The ProSeal laryngeal mask airway: a review of the literature. Can J Anesth, 2005; 52: 739 - 760. GOR = gastro-oral reflux; TT = tracheal tube; cLMA = conventional LMA; PLMA = ProSeal LMA