Chapter 17

Supraglottic Airway Devices

P. 462


Supragl ot t ic ai rway devices have become a standard f ixture in ai rway management ,
f il l i ng a ni che between the f ace mask and tracheal tube i n terms of both anatomical
posi t i on and degree of invasiveness. These devices si t outsi de the t rachea but
provi de a handsf ree means of achi evi ng a gas-t i ght ai rway.
The f i rst successf ul supragl ot ti c ai rway device, the Laryngeal Mask Ai rway (LMA)-
Cl assic, became avai l abl e i n 1989. As t ime went on, addi ti onal devices were added
t o t he LMA f amil y to sati sf y specif i c needs, and a number of other devices were
devel oped (1, 2). There are a large number of supragl ot ti c ai rway devi ces, some of
whi ch appear si mi l ar to t he LMA f ami l y and ot hers that work under a dif ferent
concept. I t i s not possi bl e to di scuss al l of t hese devi ces, because t hey are bei ng
i ntroduced at a rapi d rate whi l e others are di sappeari ng. Those that seem t o be
gai ni ng accept ance and l ongevi t y at t he t ime this wri t i ng wi l l be discussed.
Laryngeal Mask Airway Family
Types
LMA-Cl assic
Description
The LMA-Cl assic (standard LMA, Cl assic LMA, LMA-C, cLMA) consists of a curved
t ube (shaf t) connected to an el l ipt i cal spoon-shaped mask (cup) at a 30 angl e (Fig.
17.1). There are t wo f lexible vert ical bars where the t ube enters the mask to
prevent the tube f rom bei ng obst ructed by the epiglott is. An i nfl atabl e cuf f
surrounds t he i nner ri m of the mask. An i nf lat i on tube and sel f -seal ing pi l ot bal l oon
are att ached to t he proxi mal wi der end of the mask. A black l i ne runs l ongi tudi nal l y
al ong the posteri or aspect of the tube. At t he machi ne end of the tube i s a 15-mm
connector. The LMA i s made f rom si li cone and contains no l atex.

View Figure

Figure 17.1 LMA-Classic. Note the bars at the junction of
the tube and mask. (Courtesy of LMA North America.)

P. 463


TABLE 17.1 Available LMA-Classics
LMA Size Patient Size
1 Neonates/infants up to 5 kg
1.5 Infants between 5 and 10 kg
2 Infants/children between 10 and 20 kg*
2.5 Children between 20 and 30 kg
3 Children 30 to 50 kg
4 Adults 50 to 70 kg
5 Adults 70 to 100 kg
6 Adults over 100 kg
LMA, Laryngeal Mask Airway.
*Size 2.5 may be more suitable for children of this size (16).

The classi c laryngeal mask is avai l abl e i n ei ght si zes, as shown i n Tabl e 17.1. More
t han one size shoul d al ways be avai lable, because the correct si ze cannot al ways
be predi cted. When there i s doubt , a l arger rather than a smal l er si ze shoul d be
chosen f or t he f i rst at tempt (3).
Some studi es have i ndi cat ed that t he appropri ate si ze f or most adul t f emal e
pati ents is number 4 whi l e the most appropri ate si ze f or adul t mal es is 5
(4,5,6,7,8, 9,10,11, 12,13). Other st udi es f ound that both the si ze f our and f i ve may
be sui t abl e f or f emales (11, 14). I t may be more appropri ate t o use a si ze 5 f or l arge
adul ts and a si ze 4 for normal adul ts, regardless of gender (12,15).
Al ternati ve f ormul as based on wei ght have been proposed (17). A met hod t o choose
t he correct si ze l aryngeal mask f or chil dren i s to match the wi dest part of t he mask
t o t he wi dt h of the second to f ourt h f i ngers (18).
Too small an LMA wi l l predi spose to gas leaks duri ng posi tive pressure vent i l ati on.
Too l arge an LMA may tend to come up wi t hi n the mouth, may i nterfere wi t h
procedures in t he mout h (5), and may also be associ ated wi t h a hi gher i nci dence of
sore throat and other symptoms and a greater possi bi l i t y of pressure on t he li ngual
nerve.
Insertion
Standard Technique
The standard i nsert i on techni que uses a midl i ne or sl i ght l y diagonal approach wi t h
t he cuf f f ul l y def l ated (19, 20,21,22). The head shoul d be ext ended and the neck
f lexed (sni ff ing posi ti on) (23). This posi ti on i s best maintai ned duri ng i nserti on by
using t he noninserti ng hand t o stabi li ze the occiput (Fi g. 17. 2). The LMA can be
i nsert ed wi t hout pl aci ng the head i n t hi s posi ti on (24). The neut ral posi t ion may
cause a smal l decrease i n successful placement compared wi t h t he snif f i ng posi t i on
(25,26,27). The j aw may be pul l ed down by an assi stant to more f ul l y open the
mouth.
The t ube port i on i s grasped as i f i t were a pen, wi t h the i ndex f i nger pressi ng on
t he poi nt where t he tube joi ns t he mask (Fi g. 17.2). Wi th the aperture facing
f orward (and the black li ne f aci ng the pat ient' s upper l ip), t he ti p of t he cuf f i s
pl aced agai nst the i nner surf ace
P. 464

of t he upper i nci sors or gums. At t hi s poi nt , the tube shoul d be paral lel to the fl oor
(23). If t he mouth is bei ng hel d open, the j aw should be rel eased duri ng f urther
i nsert i on. In the pat i ent wi th a rest ri cted mout h opening an al ternat ive met hod i s to
pass the LMA behi nd the mol ar t eeth i nto the pharynx. The t ubular part i s then
maneuvered toward t he mi dl ine (28).

View Figure

Figure 17.2 Initial insertion of the laryngeal mask. Under
direct vision, the mask tip is pressed upward against the
hard palate. The middle finger may be used to push the
lower jaw downward. The mask is pressed upward as it is
advanced into the pharynx to ensure that the tip remains
flattened and avoids the tongue. The jaw should not be held
open once the mask is inside the mouth. The nonintubating
hand can be used to stabilize the occiput. (Courtesy of
Gensia Pharmaceuticals, Inc.)


View Figure

Figure 17.3 By withdrawing the other fingers and with a
slight pronation of the forearm, it is usually possible to push
the mask fully into position in one fluid movement. Note
that the neck is kept flexed and the head extended.
(Courtesy of Gensia Pharmaceuticals, Inc.)

As the LMA is advanced, the mask port ion is pressed agai nst the hard palate by
using t he i ndex f inger. Thi s means that the di recti on of appl i ed pressure i s dif f erent
f rom the di rect i on in whi ch the mask moves (29). I f resi st ance i s fel t , t he ti p may
have fol ded on i tsel f or i mpacted on an i rregul ari ty or the posteri or pharynx. In t his
case, a di agonal shi f t i n di recti on i s of t en hel pf ul , or a gl oved fi nger may be
i nsert ed behi nd t he mask to l i f t i t over the obst ruct ion (30). I f at any ti me duri ng
i nsert i on the mask f ai ls to stay fl at tened or starts to f ol d back, i t shoul d be
wi thdrawn and rei nserted.
A change of di rect ion can be sensed as the mask t i p encounters the posteri or
pharyngeal wal l and f ol lows i t downward. By wi t hdrawi ng t he other f i ngers as t he
i ndex f i nger i s advanced and sl ightl y pronati ng the f orearm, i t i s of ten possi bl e to
i nsert t he mask f ul l y i nto posi ti on wi th a si ngl e movement (Fi g. 17. 3). If thi s
maneuver is not successful , hand posi t i on must be changed for the next movement .
The t ube i s grasped wi t h t he other hand, strai ghtened sl i ghtl y, and t hen pressed
down wi t h a singl e quick but gentl e movement unti l a def i ni t e resi stance i s fel t (Fig.
17.4). Thi s may coinci de wi t h ant eri or l aryngeal di spl acement (30). The l ongi t udi nal
bl ack l i ne on the shaf t shoul d l i e i n the mi dl i ne f aci ng the upper l ip. Any devi ati on
may i ndi cate that the cuf f i s mi spl aced.
I f the pati ent has a hi gh, arched pal ate, a sl i ght l y l ateral approach may be needed.
The operator shoul d check that the cuff t ip i s correctl y f lat t ened agai nst t he pal ate
before proceedi ng (30). Di ff i cul ty encountered i n negoti at ing t he angle at t he back
of t he t ongue i s most commonl y t he resul t of an i ncorrect angl e of approach. The
i nsert i ng f inger must press agai nst the pal at e throughout i nsert i on.
The rat e of successful pl acement may be reduced if cri coid pressure (especi al ly
one handed) i s appl ied (25,31,32,33,34,35,36,37,38). If the f i rst i nsert i on attempt i s
unsuccessful , cri coi d pressure should be t ransi entl y rel eased whi le t he mask i s
movi ng downward during a second att empt (39).
When i ni ti al i nsert ion is unsuccessful , a number of maneuvers al one or i n
combi nati on may be helpf ul . These i ncl ude i nsert i ng t he LMA f rom the side of the
mouth; pul l i ng the tongue f orward; a j aw thrust; reposi t i oni ng the head; inserti on
wi th t he lumen faci ng backwards then rotati ng i t 180 as i t enters t he pharynx (see
bel ow); appl ying cont inuous posi ti ve ai rway pressure (CPAP); sli ght lateral rotati on;
part ial cuf f i nf l at i on; i nsert i ng a f i nger behi nd the mask to act as a gui de; usi ng a
l aryngoscope; pl aci ng a st yl et i n the LMA; usi ng a forceps; pressi ng the t ip
anteriorl y toward t he bowl whi l e the cuf f is defl ated; and usi ng a thread t o ti l t the
t i p f orward
(22,30,40, 41, 42,43,44, 45,46,47,48,49,50,51,52,53, 54,55,56, 57,58,59, 60, 61,62, 63,6
4, 65,66,67, 68,69,70,71).
When properl y pl aced, the mask rests on t he fl oor of the hypopharynx. The sides
f ace the pyrif orm f ossae,
P. 465

and the upper border of t he cuf f i s behi nd the base of the tongue (Fi gs. 17. 5, 17. 6).
The t ip of the epiglott is may rest ei ther wi t hi n the bowl of t he mask or under the
proxi mal cuff at an angl e determi ned by t he ext ent t o whi ch the mask has defl ected
i t downward (19, 63,72). I n some cases, the upper part of t he esophagus l ies wi t hi n
t he ri m of the mask. St udi es have shown t hat satisf actory f unct i on may be achieved
even when posi t i oni ng is not i deal (73,74,75,76,77,78,79,80).

View Figure

Figure 17.4 The laryngeal mask is grasped with the other
hand and the index finger withdrawn. The hand that is
holding the tube presses gently downward until resistance is
encountered. (Courtesy of Gensia Pharmaceuticals, Inc.)

180-degree Technique
Another techni que i s to i nsert t he LMA wi th the l aryngeal aperture poi nt ing
cephal ad and rot ate i t 180 degrees as i t ent ers the hypopharynx (45,81, 82, 83). A
di st inct pop may be f el t by the i ntroduci ng hand (81). Thi s method may be as
sati sf actory as the standard techni que, especiall y i n pedi at ri c pat ients. It has been
postul ated t hat rot ati on of the bulky LMA cuf f in t he cl ose proxi mi ty of t he
hypopharynx could di sl ocate the arytenoi d carti l ages (84).
Partial Inflation Technique
Yet anot her t echni que i s to parti al l y or ful l y i nf l ate t he cuff bef ore i nsert ion
(85,86,87, 88, 89,90). Al though thi s techni que may of fer some advant ages f or an
i nexperi enced user, t he device may f requent l y be mal posi t i oned (73,91). The
i nci dence of sore throat may be reduced wi t h the part i al i nf l at i on method (89).
Thumb Insertion Technique
The t humb i nsert i on techni que is more sui t abl e f or pati ents where access t o the
head f rom behi nd is di f fi cul t or impossi bl e. Insert i on i s si mil ar t o the standard
t echni que except t hat the LMA
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i s hel d wi t h the thumb i n t he posi t i on occupi ed by the i ndex f i nger i n t hat techni que.
As the thumb nears the mouth, the f ingers are st retched f orward over the pati ent' s
f ace. The thumb is advanced to i ts f ul lest extent. Bef ore removi ng the thumb, the
t ube i s pushed into i ts f i nal posi t i on by usi ng the other hand.

View Figure

Figure 17.5 The laryngeal mask in place. (Courtesy of
Gensia Pharmaceuticals, Inc.)


View Figure

Figure 17.6 Laryngeal mask airway in place. The tip of the
mask rests against the upper esophageal sphincter while the
sides face the puriform fossae.

Tracheal Intubation with the LMA-Classic
The LMA can serve as a condui t through whi ch a t racheal tube, styl et, or f i berscope
i s passed (92,93,94,95,96, 97,98,99, 100). I t acts to posi ti on t he devi ce over t he
l aryngeal apert ure. The 30 angl e bet ween the tube and cuff was chosen because i t
was f ound t o be opt imal f or intubati on t hrough the LMA (101).
Tracheal tube or f i berscope passage may be ai ded by removing t he bars at t he
j unct i on of the tube and mask (102,103). Thi s i s not recommended by the
manuf acturer. A tracheal tube wi th t he bevel point (Chapt er 19) i n the mi dl i ne may
f aci li t ate t he passage between the bars.
I t i s i mportant to understand the rel ati ve di mensi ons of the t racheal tube,
f iberscope, and LMA so that t he proper si ze tube or f i berscope can be selected.
These are given in Table 17.2.
Techniques
Blind
Bl i nd i nt ubati on through the LMA has been perf ormed in both adul ts and chil dren
(106, 107,108). The success rate i s vari abl e and depends on t echni que, t i me
avai l able, mani pul ati on of the pati ent ' s head and neck, operat or experi ence,
number of attempts, and tracheal tube used (38,109,110, 111). The success rate i n
pati ents wi t h l i mi ted neck mot ion i s lower t han i n those wi t h normal anatomy.
Because a downfolded epi gl ott i s can i mpai r bl ind i nt ubat i on, i t has been
recommended t hat i nt ubat i on through the LMA be preceded by f iberopti c
assessment of epi gl ot ti c posi t ion (112). I f the epi gl ott i s has downfol ded, movi ng the
LMA up and down wi t hout def lati ng the cuf f may hel p. Another maneuver is t o
wi thdraw t he mask about 5 cm and rei nsert i t whi l e executi ng a jaw t hrust (113).
TABLE 17.2 Maximum Size of Tracheal Tubes and Fiberscopes That Can Fit through the
LMA-Classic
Mask Size Largest Tracheal
Tube That Can Fit the LMA-Classic
(I D in mm)a
Largest Fiberscope
That Can Fit into a Tracheal Tube
(OD in mm)b
1 3.5 2.7
1.5 4.0 3.0
2 4.5 3.5
2.5 5.0 4.0
3 6.0 cuffed 5.0
4 6.0 cuffed 5.0
5 7.0 cuffed 5.0
6 7.0 cuffed 5.0
LMA, Laryngeal Mask Airway; ID, internal diameter; OD, outer diameter.
a
If the connector is removed, a larger tracheal tube can be inserted (104).
b
A larger fiberscope may be accommodated if the aperture bars are removed (105).

Af ter the LMA i s i nserted and f i xed i nt o posi ti on, the t racheal tube is wel l l ubri cat ed
and i nsert ed i nto the tube. Auscul tati ng the end of the t ube may be usef ul duri ng
spontaneous breathing. The t racheal tube should be rot ated 15 t o 90
counterclockwi se as i t i s advanced to prevent t he bevel f rom catching on the bars
at t he j unct i on of t he tube and mask. A tracheal tube wi th a midl i ne bevel point may
make thi s maneuver unnecessary. Once through the bars, the t racheal t ube i s
rotated clockwi se, and the neck i s extended to enabl e the ti p to pass anterior to t he
aryt enoi ds. The t racheal tube i s then advanced unt i l resi stance is f el t. The head i s
t hen f l exed, permi tt i ng the t ube t o advance i nto t he trachea.
An al ternate met hod of t racheal i ntubat ion i ncludes l oadi ng t he lubri cated t racheal
t ube wi th t he ti p pl aced at the l evel of t he bars i n the LMA so that when pushed
down, i t wi l l pass smoothl y t hrough the mi ddle apert ure (114).
I f the t rachea i s not entered i ni ti al l y, i t is possi bl e that t he LMA i s not wel l si tuated
over the laryngeal aperture or t he epi gl ot ti s i s bl ocki ng the apert ure. Varyi ng
degrees of neck f l exi on and extensi on at t he atl anto-occi pi tal j oi nt may be hel pf ul
(111). I f the t ube st i ll does not enter t he trachea, i t shoul d be wi t hdrawn unt i l the
bevel i s just behind the apert ure bars. The LMA cuff shoul d be
P. 467

defl ated and the LMA pushed a l i tt le f arther i nto the hypopharynx. Thi s maneuver
may cause el evati on of t he downfolded epi gl ott i s. The t racheal tube is t hen pushed
downward.
Smal l er tracheal t ubes are easi er t o place than l arger ones (115). I f the tube i s not
l arge enough, i t may be repl aced by a l arger t ube by using a tube exchanger
(Chapter 19).
The LMA can be used t o gui de a stylet, bougi e, or exchange catheter i nto t he
t rachea (42,95, 99, 116, 117,118,119,120,121, 122,123,124,125). It may be easi er t o
pass a stylet if i ts angulat ed end i s made t o poi nt anteri orl y unt il i t passes through
t he gri l l of t he mask and then rot ated 180 (126). Moni t oring carbon di oxi de through
a channel in t he exchange catheter is a usef ul way of determi ni ng that t he ti p is i n
t he trachea (127). Af ter catheter placement i s conf i rmed, t he LMA can be wi t hdrawn
and the t racheal tube i nsert ed over the cathet er.
Fiberscope Guided
The LMA-Cl assic can be used t o aid f iberopt i c-gui ded i nt ubati on. The LMA is
i nsert ed in t he usual manner. The f i berscope, wi t h a wel l -l ubri cated tracheal tube
and a f ul l y defl ated cuf f threaded over i ts shaf t , i s advanced t hrough t he LMA. The
f iberscope i s advanced i nto the t rachea, and t he tracheal t ube i s advanced over the
f iberscope i nt o the t rachea. The tube should be rotated as i t i s advanced. I t may be
useful to posi ti on the tracheal tube i n the LMA, j ust proxi mal to the apert ure bars,
before inserti ng the f i berscope. A ri ght angl e bronchoscopi c tracheal t ube
connector wi t h a seal i s at tached t o the t racheal tube. This al l ows the fi beropt ic
scope to be i nsert ed t hrough the t racheal t ube whi l e t he pati ent i s bei ng venti l ated.
Wi th this, posi tive end-expi ratory pressure (PEEP) can be appl i ed, whi ch of t en
dramat ical l y i mproves t he vi ew by st ent ing the col l apsed upper ai rway (128)
Fi berscope si ze is i mportant , especi al l y i n smal l pat i ents. The maximum di ameters
of scopes for vari ous si ze tracheal tubes are gi ven i n Tabl e 17.2.
The l aryngeal mask has proved equal or superi or t o other devices designed to aid
wi th i nt ubati on usi ng a f i berscope (129,130). Thi s i ntubat ion method has been used
i n i nf ants as smal l as 3.6 kg (131). Thi s method has a hi gher success rate than the
bl i nd method and i s associ ated wi t h l ess ri sk of t rauma or esophageal i nt ubati on
(96,132,133,134). An i nspecti on of t he tracheobronchi al t ree can be made. I t i s
useful for pat ients i n whom neck movement needs to be avoi ded (135).
A f i berscope may be used to i nsert a bougie or other gui de i nto t he t rachea through
an LMA
(97,119,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,1
42,143,144,145, 146,147, 148). The LMA can t hen be removed and a tracheal tube
i nsert ed over t he gui de. Thi s techni que al l ows a l arger tracheal tube to be pl aced
and avoi ds the danger of acci dent al extubati on when the LMA i s removed (97, 143).
Retrograde
The LMA can be used t o facil i tat e tracheal i nt ubati on by usi ng a retrograde wi re
t echni que (149,150,151) (Chapter 21). The gui de wi re i s i nserted through t he
cricot hyroi d membrane and passed cephal ad. A guide cathet er i s t hen t hreaded
antegrade over the wi re. The LMA is then removed and a t racheal t ube passed over
t he catheter.
Lighted Stylet Guided
Tracheal i ntubat i on by usi ng a l i ghted styl et placed through a tracheal tube that i s
i nsert ed through an LMA-Cl assi c has been descri bed (152,153,154,155). The st yl et
t i p i s posi t ioned at t he pat ient end of the t racheal t ube and i s advanced through the
LMA. If a central point of l i ght i n the anteri or neck is observed, the LMA cuff i s
sui tabl y pl aced around the l aryngeal i nl et. If t ransi l l umi nat i on is not seen, the LMA
i s reposi ti oned i n the pharynx accordi ng to the l ocat ion of the l i ght . Tracheal
i ntubat ion i s accompl i shed by advanci ng the l ight ed stylet unti l the suprasternal
notch i s transi l l uminated. The success of i nt ubat i on wi t h this method i s comparabl e
t o bl i nd i ntubat ion (155,156).
Nasotracheal Intubation
The LMA has been used to f aci l i tate nasot racheal i ntubati on (157). The LMA i s
i nsert ed and a catheter pl aced in t he trachea. Another catheter is i nsert ed into the
nose and brought out through the mouth. The LMA i s removed wi t h t he catheters in
pl ace. The catheters are sutured t ogether and t racti on appl i ed to the nasal cathet er
so t hat t he curve i n the mouth i s removed. The tracheal tube i s then insert ed over
t he catheters i nt o the l arynx.
Another method to perf orm nasot racheal intubati on i s to cut a wi ndow i n t he
posteri or aspect of t he LMA' s tube near t he mask and remove the apert ure bars
(158). A f i berscope mount ed wi th a tracheal tube i s i nserted via the nose through
t he wi ndow i n t he LMA and i nto the trachea.
Another method is t o insert the LMA and then part i al l y wi thdraw t he cuf f i nto t he
oropharynx, where i t can suppl y f resh gas to t he spontaneousl y breathi ng pati ent
(159). Nasotracheal i nt ubati on is t hen accompl i shed by usi ng a f i berscope.
Problems Associated with Tracheal Intubation through the
LMA-Classic
Some standard t racheal tubes may not be long enough to i nsert t hrough t he LMA-
Cl assic (160). Deeper pl acement can be achieved by usi ng a l onger tracheal tube
(134, 161,162,163, 164, 165,166, 167, 168,169, 170,171,172,173,174), shortening t he
LMA tube (139, 175, 176), removi ng the connect or f rom t he LMA, def l at ing t he LMA
cuff (160) usi ng a spl i t LMA (92,102), or usi ng a device such as a st yl et t o advance
t he tracheal t ube f art her (108). Consi deration should be gi ven to usi ng an ai rway
exchange cathet er (177).
As the tracheal t ube i s passed through the LMA-Cl assic, the pi l ot t ube may become
ki nked (178).
P. 468


When i nt ubat i ng a pedi at ri c pati ent wi th an uncuf fed t racheal tube through an LMA-
Cl assic, the l argest tube that wi l l pass through the LMA may be too smal l t o al low a
good seal during posi ti ve pressure vent i l at ion. Leavi ng the LMA i n pl ace wi th t he
cuff i nf lated wi l l reduce t he leak (179). If a cuff ed tube i s used, i t may be
i mpossible t o remove the LMA wi thout damagi ng the i nf lati ng device (180).
Cri coid pressure may make i t more di ff i cul t t o pass a tracheal tube
(38,181,182,183). If i ntubat i on is i ni ti al l y unsuccessful and i ntubat i on is deemed
vi tal , a second att empt should be made wi t h t ransi ent rel ease of cricoi d pressure.
Changi ng f rom one-handed to bi manual cri coi d pressure appl i cati on may be hel pf ul .
LMA-Classic Removal after Tracheal Intubation
The deci si on to remove the LMA-Classi c af ter t racheal i ntubat ion or to l eave i t i n
pl ace depends on the ci rcumstances. Reasons to remove t he LMA incl ude concern
about pressure on the sof t t i ssues, t he need t o keep i t away f rom the surgi cal f i el d,
a possi bl e i ncrease i n gastroesophageal ref l ux, and di ff icul t y i n placing a gast ri c
t ube (184).
Many users prefer t o leave the LMA-Cl assi c i n pl ace af ter i ntubat ion t o provi de an
al ternati ve ai rway at t he conclusi on of the anestheti c (185, 186, 187). I f t hi s i s done,
t he protrudi ng end of the t racheal tube shoul d be f i rml y secured.
There i s no si mpl e way t o remove the LMA wi t hout disturbi ng the trachea t ube. An
LMA may be modi f ied by spl i t ti ng t he tube and cuf f so t hat i t can be more easi l y
removed over the tracheal t ube (102,188). A smal l t racheal t ube or other devi ce
may be pl aced in t he end of t he t racheal tube to act as a pusher (ext ender) t o
prevent extubati on as t he LMA is wi thdrawn (94,189,190, 191,192). A f iberscope,
bougi e, j et st yl et , or t ube changer may be passed through the t racheal tube to
f aci li t ate rei ntubat ion i f extubat ion occurs as the LMA i s bei ng removed (193).
LMA-Uni que
The single-use LMA-Uni que (di sposable l aryngeal mask ai rway, DLMA) is shown i n
Fi gure 17. 7. Si zes are gi ven i n Tabl e 17.3. I t i s made of pol yvinyl chl ori de and costs
l ess than a reusabl e LMA. Whi l e the di mensi ons are i denti cal to t he standard LMA,
t he tube is st i ff er and t he cuff l ess compl i ant. It may be helpful to warm i t pri or to
i nsert i on to make i t sof ter and more compl i ant .
I ndi cat i ons are the same as f or t he LMA-Cl assi c. I t may be a bett er choi ce for out -
of -hospi t al or ward use, where i t woul d be di ff icul t to cl ean and steri li ze a reusable
LMA af ter use. Insert i on and pl acement of the LMA-Uni que i s si mil ar t o the LMA-
Cl assic. If i t i s used f or f i beropti c i ntubati on, short eni ng t he tube may be hel pf ul
(176).
Compari sons of the LMA-Uni que wi t h the LMA-Cl assic show l i tt l e dif ference in ease
of i nsert i on or perf ormance (194,195,196), al though the LMA-Uni que may be
somewhat more di ff i cul t to i nsert (197). The i nt racuf f pressure i ncreases
si gni f icant l y l ess i n the LMA-Uni que when ni trous oxide i s used (198,199).

View Figure

Figure 17.7 LMA-Unique.

One study f ound t hat a 3-mm or 4-mm i nternal di amet er (ID) t racheal t ube could not
be i nsert ed through the LMA-Uni que (200). A st ructural problem resul t ing i n a leak
has been reported (201).
LMA-Flexible
Description
The LMA-Fl exi bl e (wi re-rei nforced, reinf orced LMA, RLMA, FLMA, f l exible LMA)
(Fi g. 17.8) di f fers f rom the LMA-Cl assic i n that i t has a fl exi bl e, wi re-rei nf orced
t ube (202, 203, 204). Thi s tube i s longer and narrower than the t ube on the LMA-
Cl assic. It i s avai l abl e i n t he si zes shown i n Tabl e 17.4. The cuff si zes are the
same as f or t he LMA-Classi c. A si ngle-use version i s al so avail abl e. The si zes f or
t he si ngl e-use versi on are the same as for t he mul ti use one.
TABLE 17.3 Sizes of the LMA-Unique
Mask
Size
Patient Size
(kg)
Maximum Cuff
Volume (mL of air)
Largest Tracheal
Tube (I D in mm)a
Largest Flexible
Endoscope (I D in mm)b
1 Up to
5
4 3.5 2.7
1.5 5 to 10 7 4.0 3.0
2 10 to
20
10 4.5 3.5
2.5 20 to
30
14 5.0 4.0
3 30 to
50
20 6.0 5.0
4 50 to
70
30 6.0 5.0
5 70 to
100
40 7.0 5.5
ID, internal diameter.
a
If the connector is removed, a larger tracheal tube can be inserted (104).
b
A larger fiberscope may be accommodated if the aperture bars are removed (105).

P. 469



View Figure

Figure 17.8 LMA-Flexible. The wire-reinforced tube is
longer and has a smaller diameter than the standard LMA.

The f lexi bl e t ube can be bent to any angl e wi t hout ki nki ng. This al l ows i t to be
posi t i oned away f rom t he surgi cal f i el d wi t hout occl uding the l umen or l osing t he
seal against the larynx. I t is l ess l i kel y to be di splaced duri ng head rotati on or t ube
reposi t ioni ng than the LMA-Cl assi c.
Insertion
The LMA-Fl exi bl e is more di f f icul t to i nsert t han the LMA-Cl assi c. A st yl et , smal l
t racheal tube, or other device may be i nserted i nto t he tube to st i ff en i t
(205, 206,207,208, 209, 210,211, 212, 213,214, 215). The manuf acturer recommends
t hat i t be held bet ween t he t humb and i ndex f i nger at the j uncti on of the t ube and
cuff and posi t i oned by i nserti ng the i ndex f inger t o i ts ful l est extent i nto t he oral
cavi t y unt i l resi stance i s encountered. I t may be necessary t o use the other hand to
achieve full i nsert i on. I t may be easi er to i nsert by usi ng the t humb, index, and
mi ddl e f i ngers at t he j unct i on of t he tube and bowl , t hen usi ng the i ndex and mi ddl e
f inger t o advance i t into the hypopharynx (216). A modi f i ed Magi l l f orceps or other
device may be useful (59,212,217). Other met hods f or i nsert i on have been
descri bed (218). Some techni ques such as the 180-degree t echni que may not work
wi th t hi s LMA (202). Af ter i nserti on, the tube may be brought out through the nose
(219).
Use
The LMA-Fl exi bl e is desi gned f or use wi t h surgery on the head, neck, and upper
t orso where t he LMA-Classi c woul d be i n the way. A t hroat pack shoul d be used i f
t here i s a ri sk of dental f ragments becoming wedged behi nd the cuf f (202). I f
mal occlusi on testi ng i s needed, t he tubing can be coi l ed insi de the mouth (220).
Compari sons bet ween t he LMA-Cl assi c and LMA-Flexi bl e reveal that both are
si mi l ar i n terms of mask posi ti on, cl i ni cal perf ormance, and pharyngeal mucosal
pressures (221,222).
Problems
The wi re rei nf orcement makes t he LMA-Flexi ble more resistant to ki nki ng and
compressi on than the LMA-Cl assic but does not prevent obstruct i on f rom bi ti ng.
Ai rway obst ructi on and l oss of seal have been reported when a Boyl e Davi s gag
was used (223,224,225). This can usual l y be corrected by reposi ti oning t he gag.
The spi ral rei nf orcing wi re i n the LMA-Fl exible may become di srupt ed. Someti mes,
t he di srupti on i s i nternal and can onl y be discovered by l ooki ng careful l y down t he
shaf t (226). Defects i n the wi re may cause obst ructi on i f the t ube i s bent, or pi eces
of wi re coul d break of f and mi grate i nto t he tracheobronchi al t ree (226,227).
The small di ameter of the tube l i mi ts t he si ze endoscope or tracheal t ube t hat can
be passed t hrough the LMA-Fl exi ble (105). I t has been recommended that
prol onged spontaneous vent il ati on be avoi ded because the smal l er t ube causes
i ncreased resistance (202,228).
The LMA-Fl exi bl e is unsui tabl e f or magnet ic resonance imagi ng (MRI) scanning i f
i mage quali ty i n the regi on of t he LMA i s i mportant (229). The metal l ic rings wi l l
cause i mage di stort i on (229).
Mal posi t i on is l ess easi l y di agnosed wi t h t he LMA-Fl exi bl e t han wi t h t he LMA-
Cl assic because the tube gi ves no clear i ndi cat ion of cuf f ori ent ati on (230).
TABLE 17.4 Size Comparison between Standard and Flexible Laryngeal Mask Airways
LMA
Size
Patient Size
(kg)
LMA-Flexible
(I D in mm)
LMA-Classic
(I D in mm)
LMA-Flexible
Tube Length
(cm)
Maximum Cuff
I nflation Volume
(mL)
2 10 to
20
5.1 7.0 21.5 Up to 10
2.5 20 to
30
6.1 8.4 23.0 Up to 14
3 30 to
50
7.6 10.0 25.5 Up to 20
4 50 to
70
7.6 10.0 25.5 Up to 30
5 70 to
100
8.7 11.5 28.5 Up to 40
6 >100 8.7 28.5 23.5 Up to 50
LMA, Laryngeal Mask Airway; ID, internal diameter.

P. 470


LMA-Fastrach
The LMA-Fastrach (intubat ing LMA, ILMA, ILM, i ntubati ng l aryngeal mask ai rway)
was desi gned to overcome some of the l i mi tat ions of the LMA-Cl assi c during
t racheal int ubati on (231, 232,233,234,235,236,237,238). The LMA-Cl assic was t oo
f loppy to opti mize ali gnment wi th t he gl ot ti s, and the l ong narrow tube coul d not
accommodate a standard t racheal tube. Another obj ecti ve was t o el i mi nat e the
need to di stort the anteri or pharyngeal anatomy i n order to visual i ze the l aryngeal
i nl et, maki ng the devi ce appli cabl e to pat ients wi th a hi st ory of di ff i cul t intubat ion
and a hi gh or anteri or l arynx (234).
Description
The LMA-Fastrach (Fi g. 17.9) has a short, curved st ai nl ess steel shaf t wi th a
standard 15-mm connector. The tube is of suf fi ci ent di ameter that a cuf f ed 9-mm
t racheal tube can be i nserted and short enough to al low a st andard t racheal tube
cuff t o pass beyond the vocal cords. The metal handl e i s securel y bonded to t he
shaf t near t he connector end to f aci l i tate one-handed i nserti on, posi ti on
adj ustment, and mai ntai n the devi ce i n a steady posi t i on during t racheal t ube
i nsert i on and removal . There is a si ngl e, movable epi gl ot ti c el evator bar i n pl ace of
t he two vert ical bars (Fig. 17. 10A). A V-shaped gui ding ramp i s bui l t i nt o the f l oor
of t he mask aperture to di rect the tracheal tube toward the glott is. The t i p i s sli ghtl y
curved t o permi t atraumati c inserti on. Fi gure 17.10B shows t racheal tube prot rudi ng
t hrough the LMA tube and into the bowl .
The LMA-Fastrach does not contai n latex. It i s avail abl e i n si zes 3, 4, and 5. These
f i t the same si ze pati ents as the LMA-Classi c. Both reusable and disposabl e
versi ons are avai l able.
Insertion
The LMA-Fastrach was desi gned f or use wi t h the pati ent in t he neut ral posi t i on
(231). Thi s i ncl udes usi ng a head support, such as a pi l l ow, but no head ext ension.
The i nsert i on t echni que consi sts of one-hand movements i n the sagi tt al pl ane. I t
does not requi re placi ng f i ngers i nto t he pati ent 's mouth, thus mi ni mi zi ng the risk of
i nj ury or i nf ecti on transmissi on as wel l as al l owi ng i nsert i on f rom al most any
posi t i on (234,239).

View Figure

Figure 17.9 LMA-Fastrach with tracheal tube. The tube on
the LMA is shorter and wider than on the LMA-Classic and
has a metal handle. Note that the tracheal tube connector has
been removed. (Courtesy of LMA North America.)

The LMA-Fastrach shoul d be def l ated and lubri cated i n a manner simi l ar to the
LMA-Classi c. I t i s hel d by the handl e, whi ch shoul d be approximatel y paral lel to the
pati ent 's chest . The mask ti p is posi ti oned f l at against the hard pal ate i mmedi at el y
posteri or t o t he upper
P. 471

i nci sors, t hen sli d back and f orth over t he pal at e to di st ri bute the l ubri cant . Af ter
t he mask i s f l at tened agai nst the hard palate, i t i s inserted wi t h a rot ati onal
movement along the hard pal ate and t he posteri or pharyngeal wal l . The mouth
openi ng may need t o be i ncreased momentari l y to permi t the wi dest part of t he
mask t o enter t he oral cavi t y. The handle shoul d not be used as a l ever t o force the
mouth open. As the mask moves toward t he pharynx, i t should be f i rml y pressed to
t he sof t pal ate and posteri or pharyngeal wal l t o keep the ti p f rom f ol di ng. The
curved part of the metal tube should be advanced wi thout rotati on unt i l i t contacts
t he pat ient' s chin, then kept i n contact wi th t he chi n as the devi ce i s rotat ed inward.
The handl e should not be used to l ever upward during i nsert ion, because thi s wi l l
cause the mask to press int o the t ongue.

View Figure

Figure 17.10 LMA-Fastrach. A: Note the single, movable
epiglottic elevator bar and the V-shaped guiding ramp built
into the floor of the mask aperture to direct the tracheal tube
toward the glottis. B: Tracheal tube emerging from the
LMA.

When properl y inserted, the t ube shoul d emerge f rom the mouth di rected somewhat
caudal l y. Al igni ng the i nternal LMA-Fastrach apert ure and the glott ic openi ng by
f inding the posi ti on that produces opt i mal venti l ati on and then appl yi ng a sl i ght
anterior l i f t wi t h the LMA-Fast rach handl e faci l i tates correct posi t i oni ng and bl ind
i ntubat ion (240).
The LMA-Fastrach can be inserted wi t h a 180 rotat i on techni que (241).
Use
Al though t he LMA-Fast rach has been desi gned to f aci l i tate t racheal i ntubat ion, i t
can also be used as a pri mary ai rway devi ce. It i s especi al l y usef ul f or t he
anti ci pat ed or unexpect ed dif f icul t ai rway
(231, 240,242,243, 244, 245,246, 247, 248,249, 250,251,252,253,254,255,256,257,258,
259,260,261,262,263,264,265,266,267,268,269).
St udi es i ndi cate that most i nsert i on at tempt s wi th t he LMA-Fast rach are successf ul ,
and a patent ai rway i s secured in nearl y al l pati ents
(231, 237,240,245, 247, 250,253, 258, 265,270, 271,272,273,274,275). I t has been
used successful l y in chi l dren (276), morbidl y obese pati ents (277,278, 279), and
acromegal ic pati ents (280).
The LMA-Fastrach can be inserted wi t h t he same or bet ter success t han t he LMA-
Cl assic (281, 282,283,284). It i s easi er to pl ace than t he LMA-Cl assi c when manual
i n-l i ne st abi l i zati on is used (285). However, i n pati ents wi t h l i mi ted neck movement ,
i ntubat ion may be l ess l i kel y t o be successf ul and take l onger t han i f a l ighted
i ntubat ion stylet is used (286).
The LMA-Fastrach has been used successful l y i n the emergency depart ment and
prehospi tal care (265,282,287,288,289,290). I t can be used wi th the pati ent in t he
l ateral posi t ion (291,292,293,294).
Tracheal Intubation
Muscle rel axants are not necessary for i ntubati on through the LMA-Fast rach but
may i ncrease the success rat e (295,296,297,298,299). Cri coid pressure wi l l
decrease the l i kel i hood of success and may need t o be rel eased to al l ow i nt ubati on
(182).
The t racheal tube recommended by the manuf acturer f or use wi th t he LMA-Fast rach
i s a sil i cone, wi re-rei nf orced, cuf fed tube wi t h a tapered pati ent end and a bl unt t ip
(236, 300,301) (Chapter 19). This tube i s fl exi bl e, which all ows negot iat i on around
t he anatomi cal curves of t he ai rway. I t has a hi gh-pressure, low-vol ume cuff that
reduces resistance duri ng intubati on and makes cuff perf orati on as the tube passes
t hrough the LMA l ess l i kel y. There i s a stabi l i i zer t hat al l ows t he LMA to be
removed wi t hout extubat i ng the pati ent .
When using the LMA-Fast rach, standard curved pl asti c tracheal tubes are
associ ated wi th a great er l ikel i hood of l aryngeal trauma (302,303). Warming a
pl ast i c tube wi l l resul t i n success and compl i cat ion rates si mi l ar t o that of t he tube
f rom the LMA-Fast rach manuf acturer (301). A spi ral -embedded tube should not be
used. If a curved pl asti c tracheal tube i s used, i t may be hel pf ul to ori ent the curve
opposi te t he LMA curve (265, 272,303).
Whatever tracheal t ube i s used, i t is essenti al that i t i s possi bl e to remove the
connector (304). I t i s important to lubri cate t he tracheal t ube wel l and pass i t
t hrough the LMA several t i mes bef ore use (305).
Blind Intubation
The pati ent ' s head i s maintai ned i n the neutral posi ti on. The t racheal tube
connector should be l oosel y f i t t ed for easy removal . The tracheal tube shoul d be
l ubricated wi t h a water-sol ubl e lubri cant and passed i nt o the met al shaf t of the
LMA-Fastrach unt i l the tube t i p i s about t o enter the mask apert ure. Wi th the
si l icone tracheal tube speci al l y desi gned f or t he LMA-Fastrach, the l ongi t udi nal li ne
shoul d face t he handl e of the LMA, and the t racheal t ube shoul d not be passed
beyond t he poi nt where the transverse l i ne on the tube is l evel wi th t he out er ri m of
t he LMA-Fast rach ai rway t ube.
The LMA-Fastrach handl e is grasped wi t h one hand to st eady i t whi l e the t racheal
t ube i s bei ng i nserted, then l i f ted l ike a l aryngoscope (not l evered) t o draw t he
l arynx forward a few mi l l i meters. Thi s i ncreases t he seal pressure and hel ps to
al i gn the axes of the trachea and t he tracheal tube. It also corrects t he tendency f or
t he mask t o f l ex.
As i t is advanced i nto t he LMA-Fast rach, t he t ube shoul d be rotat ed and moved up
and down to di st ri bute the l ubri cant. Venti l at i on and carbon di oxi de moni t ori ng can
be perf ormed duri ng t racheal tube i nsert i on by connect i ng the t racheal tube to t he
anesthesi a breathi ng system.
The t racheal tube should be advanced gentl y. The LMA-Fast rach handle shoul d not
be pressed downward. If no resistance if f el t , i t i s l ikel y that the epigl ot t ic el evati ng
bar is l if t ing the epi gl ot ti s upward, al l owi ng t he tracheal t ube t o pass i nto t he
t rachea. When the t racheal tube is thought t o be in t he trachea, the cuf f shoul d be
i nf l ated and i ts posi ti on i n the t rachea conf i rmed (Chapter 19).
I f the t racheal tube fail s to enter the t rachea, a number of probl ems may have
contri but ed to t he lack of
P. 472

success (234,270). The epigl ot ti s may have f ol ded downward, or the t ube may have
i mpacted on the peri gl ot t ic st ruct ures. The LMA-Fastrach may be t oo smal l or too
l arge f or t he pati ent . The l arynx may have been pushed downward duri ng i nsert i on.
There may have been i nadequate anesthesi a or muscl e rel axati on so t hat t he vocal
cords were cl osed.
During bli nd t racheal intubati on, the operator rel i es on tact i l e percepti ons,
especi al l y a f eel i ng of resi stance, whi l e advancing the t racheal tube (234). I f t he
mask i s not ali gned wi t h the gl ot tic openi ng or t he si ze of the LMA-Fast rach is
i nappropri at e, resi st ance wi l l be encountered as the t racheal tube ti p pushes
against gl ot ti c or peri gl ot ti c structures, such as the downfolded epi gl ott i s,
vall eculae, arytenoi ds, or aryepi gl ot ti c folds.
I f resistance i s f el t af ter the t racheal tube leaves the LMA-Fastrach, there are a
number of maneuvers that can be taken to rel ieve the si t uat i on. I f resi st ance i s fel t
at 2 cm beyond t he 15-cm mark on the tracheal tube, i t is l ikel y t hat the t ube has
i mpacted on the vesti bul ar wal l . Rotat ing the t racheal bevel may overcome the
i mpacti on. Another probl em at t his l evel may be a downfol ded epi glott is. Wi thout
defl ati ng t he cuf f , the devi ce shoul d be swung outward f or 6 cm and rei nsert ed
(234). I f resistance is encountered 3 cm beyond 15 cm, the epigl ot ti s may be out of
t he reach of the el evat i ng bar, and a l arger LMA shoul d be used. If resi stance
occurs i mmedi atel y af ter t he t racheal tube l eaves the LMA-Fast rach, the LMA may
be too large and should be repl aced wi t h a smal l er one (270). I f resi st ance i s fel t at
15 pl us 4 cm, t he LMA may be too large, and a smal ler si ze should be used (239).
Ot her maneuvers t hat can be tri ed i nclude sl i ghtl y rot at ing the LMA-Fastrach i n the
sagi t t al pl ane by usi ng the met al handl e unt i l the l east resi stance t o manual
venti l ati on i s achi eved, removing the head support , pul l ing t he metal handl e toward
t he user (extensi on), or pushi ng i t away f rom the user (f l exi on) (237,240,258,265).
The LMA-Fastrach can be used to pl ace an ai rway exchange catheter, whi ch can
t hen be used to di rect a tracheal tube i nto the t rachea (306).
Bl i nd i nt ubati on usi ng the LMA-Fast rach is f ast er t han f iberopti c-gui ded i ntubati on
or i ntubati on usi ng di rect l aryngoscopy (272,307). It can be perf ormed awake (248).
When compared wi t h awake f i beropt ic i ntubat i on for pat ients wi th known di ff i cul t
ai rways, pat ient sat i sfact ion was greater wi t h the LMA-Fastrach (250).
The success rate of bl i nd i ntubat ion vari es f rom 40% to 100%
(231, 235,237,240, 243, 245,248, 256, 258,265, 270,271,272,275,276,280,300,307,308,
309,310,311,312,313,314,315,316,317,318), depending on the number of attempts
and the experi ence of the operat or.
The bl i nd techni que can be ti me consumi ng and may resul t i n trauma or esophageal
i ntubat ion (237,245,271,309,310,312,319,320,321,322,323). I f di f fi cul t y i s
encountered, the use of an LMA-CTrach shoul d be consi dered.
Blind Nasal Intubation
Bl i nd nasal i ntubati on can be accompl ished (324). A f l exi bl e t racheal tube i s
i nsert ed int o the t rachea t hrough t he LMA, whi ch i s t hen removed. A Fol ey cathet er
i s i nt roduced i nto the nose and wi t hdrawn f rom the mouth. The Fol ey catheter is
i nsert ed int o the end of t he tracheal t ube and inf l ated wi t h sal i ne to grip t he inner
wal l s. The Fol ey cathet er i s then wi t hdrawn unti l the machi ne end of t he t racheal
t ube exi ts through the nose.
Fiberscopic-guided Intubation
The LMA-Fastrach i s useful for f i beropt ic i nt ubat i on in t he di ff icul t-to-i ntubat e
pati ent (263). The fi berscope is used to observe correct t racheal tube passage
t hrough the LMA. The epiglot t ic el evati ng bar is t oo st if f t o be el evated by a
f iberscope wi thout risk of damagi ng the t ip or di recti ng i t downward (239, 325,326).
I t should be l i f t ed by the distal end of t he t racheal tube (327).
The t racheal tube is advanced approximatel y 1. 5 cm past the mask apert ure whi le
t he i ntubati ng metal handl e of the LMA-Fastrach is held t o stabi li ze i t. The ti p of the
t racheal tube should now have l i f ted t he f i berscope away f rom the bowl of t he
mask, exposi ng t he gl ott i c structures. The fi beropti c scope i s i nserted and
advanced to, but not beyond, the di stal end of t he tracheal tube. The t racheal tube
i s advanced unti l t he gl ott i s is brought i nto vi ew. The tracheal t ube i s then
advanced into the trachea.
I f di f f icul ti es are encount ered, t he pati ent' s head and neck may be maneuvered or
t he LMA-Fast rach posi t ion adjusted by usi ng t he metal handle (228).
Fi beropt i c i ntubati on has a hi gh success rate (134,240,272,311,328). It can be
perf ormed awake (257,261,329,330,331). I t has been used i n pat i ents wi t h unstabl e
necks (261,328,330). It i s easi er t han i nt ubati on wi th a ri gi d laryngoscope or using
onl y a fi berscope i n pati ents wi th manual i n-l i ne st abi l i zati on (259,328). I t al lows an
exami nati on of the l ower ai rway. It can be performed easier and i n less ti me if the
recommended t racheal tube i s used (332).
During f i beropt ic i ntubat i on wi t h a si ze 3 or 4 LMA-Fast rach, vent i l at ion may be
i nadequate (333). Wi t h a size 5 LMA, venti lat i on is general l y acceptabl e.
The LMA-Fastrach can be used wi t h an opti cal st yl et (334).
Light-guided Intubation
An i l l umi nat ed f l exibl e f i ber or a l i ghted i nt ubati on styl et inserted t hrough t he
t racheal tube extendi ng j ust beyond t he t racheal tube ti p can be used to guide a
t racheal tube i nt o the glot t ic openi ng
(247, 270,291,292, 308, 310,312, 322, 335,336, 337,338,339,340,341,342,343,344). A
di st inct central poi nt of l i ght wi t hout a hal o i n the mi dl ine i ndi cates correct
pl acement . Once correct posi ti on i s achi eved, t he t racheal tube i s advanced.
I f resistance i s f el t, correct transil l umi nat ion i s not observed or the l i ght point is
seen movi ng l ateral l y, t he tracheal t ube shoul d be wi t hdrawn 1 cm beyond
P. 473

t he epi gl ott i c elevator bar and one or more of the f ol lowi ng adj usti ng maneuvers
appli ed, dependi ng on the cause of resi stance and observati on of t he l i ght bef ore
each addi t ional i ntubati on att empt : f lexi on or extension of the handle, wi t hdrawi ng
t he LMA-Fast rach by 5 cm f ol lowed by reinserti on, perf ormi ng manual vent i l ati on
and adjust ing the LMA-Fast rach posi t i on unt i l the opti mal seal i s obtai ned, fl exi ng
t he neck and ext endi ng t he head, usi ng a smal l er t racheal tube, usi ng a l arger or
smal l er LMA-Fastrach, or t wi st i ng the LMA handl e (270,322,335,336,338, 340,345).
Li ght -gui ded i ntubat ion can decrease the t ime to successful intubati on and t he
number of attempts and f ai l ures when i nserti ng a t racheal tube through the LMA-
Fastrach compared wi t h bl ind i nt ubati on (308, 310, 312,336, 339, 340).
Removing the LMA-Fastrach after Intubation
Af ter the t rachea has been i ntubat ed, t he deci si on needs to be made whether to
remove the LMA-Fast rach or t o l eave i t i n pl ace. It i s usual ly recommended that t he
LMA-Fastrach be removed (346,347,348). Al ternat el y, t he cuff can be def lated t o 20
t o 30 cm H
2
O and the LMA-Fastrach l ef t i n si tu (349). The LMA-Fast rach may exert
mucosal pressures i n excess of capi ll ary perf usi on pressure (348). Pati ents i n
whom t he LMA-Fast rach is retained have a hi gher inci dence of hoarseness, sore
t hroat, and dysphagia (246, 346).
Removing the LMA i s associ ated wi t h a hemodynami c response (350). Del aying
removal for a f ew mi nutes may sl ightl y decrease the associ ated pressor response
(273, 351).
The t racheal tube needs to be stabi l ized to prevent extubati on duri ng LMA-Fast rach
removal . The tube connector needs to be removed. A st abi l i zer rod (extender) t hat
i s placed i n t he end of the t racheal tube i s avai labl e f rom the manufacturer (Fi g.
17.11). I nsert ing t he t ip of a small er t racheal tube into the end of the i nsert ed
t racheal tube wi l l al l ow vent i l at ion whi l e the LMA-Fast rach is bei ng removed (352).

View Figure

Figure 17.11 To stabilize the tracheal tube and to prevent
extubation during LMA-Fastrach removal, a stabilizer rod
(extender) is placed in the end of the tracheal tube.

The LMA-Fastrach cuff is def l at ed, and t he LMA-Fastrach i s swung out of t he
pharynx into the oral cavit y whi l e appl ying counterpressure to t he t racheal tube
(239). The st abil i zing rod i s removed when t he LMA-Fast rach cuf f i s cl ear of t he
mouth. The tracheal t ube i s then f i rml y grasped whi l e unt hreadi ng the inf l ati on t ube
and pi l ot bal l oon f rom t he LMA-Fast rach. Fi nal l y, the t racheal tube connector i s
repl aced.
Problems with Intubation
Pharyngeal pathol ogy may make intubati on t hrough the LMA-Fast rach i mpossi bl e
(311, 331,353).
Currentl y, t he smal l est si ze avai l abl e of the LMA-Fast rach is the number 3. This
has been f ound t o work wel l f or i nt ubat i on of pat i ents over 30 kg, but f or pati ents
under t hi s wei ght, successful intubati on t hrough t his devi ce i s l ess certai n (313).
The LMA-Fastrach t racheal tube is expensive and shoul d not remai n i n pl ace f or
l ong peri ods of t i me because i t has a hi gh-pressure cuf f .
The LMA-Fastrach requi res more t ime f or i nt ubat ion and resul ts i n more esophageal
i ntubat ions and mucosal trauma than ri gi d laryngoscopy (309). Bl i nd i ntubati on
t hrough the LMA-Fast rach generat es cardi ovascular responses si mil ar t o tracheal
i ntubat ion usi ng di rect l aryngoscopy (309, 350,354).
When t he LMA-Fast rach is removed, the tracheal t ube may be displaced downward
or disl odged (276).
Problems
The ri gid LMA-Fastrach shaf t cannot easi l y adapt t o a change i n the posi ti on of the
pati ent 's neck. It i s more l i kel y to be di sl odged than the LMA-Cl assic i f head or
neck mani pul ati on i s requi red. It should not be used i n cases where the pati ent wi l l
be i n the prone posi ti on.
The LMA-Fastrach i s unsui tabl e f or use i n the MRI uni t.
A case of obstruct ion af t er t he LMA-Fast rach was i nserted has been report ed (355).
Fi beroscopy revealed t hat the epi gl ot t ic el evati ng bar was i n the laryngeal aperture,
and though i t l i f ted the epi gl ott i s, the arytenoi d carti l age was pressed ant eri orl y by
t he LMA-Fast rach cuf f , part i al l y obstruct i ng the l aryngeal apert ure. Despi te the
obstruct i on, the trachea was i ntubated successful l y.
The l arge di amet er of the LMA-Fast rach ai rway tube can cause di ff icul t y duri ng
i nsert i on i n the pati ent wi t h a l i mi ted mout h opening and may put dent i ti on at ri sk
(356, 357). Compared wi t h the LMA-Cl assic, the LMA-Fastrach causes an increased
i nci dence of sore throat, sore mouth, and di f f i cul ty swal lowi ng (358).
Whi le LMA-Fastrach i s easi er t o pl ace t han t he LMA-Cl assi c and pl acement i s more
l ikel y to be successful i n
P. 474

pati ents wi t h i mmobi l i zed cervi cal spi nes (240,285,329), the LMA-Fast rach may
exert pressure on the cervical spi ne (348,359). Intubati on t hrough the LMA-
Fastrach may cause si gnif icant moti on of the cervi cal spi ne. I t may be dif f i cul t t o
i nsert i n the pati ent wi t h a cervical coll ar, especi al ly i f cri coi d pressure is used
(256).
Anesthesi a provi ders who have l i mi t ed use of the l ef t arm wi l l fi nd the LMA-
Fastrach di f f i cul t to use (360).
LMA-CTrach
Description
The LMA-CTrach (Fig. 17.12) i s si mi lar i n const ructi on to t he LMA-Fastrach
(361, 362). I t has t wo bui l t-i n f i beropti c channel s, one to convey l i ght f rom and the
ot her t o convey t he image to the viewer. These emerge at the distal end of t he
ai rway tube under the epiglot t ic el evati ng bar, whi ch l i f ts the epi gl ot tis as the
t racheal tube passes through the LMA-CTrach i nt o the l arynx. The fi beropt i c syst em
i s seal ed and robust, so the LMA-CTrach can be autocl aved.
The moni tor (vi ewer) i s att ached to the LMA-CTrach via a magnetic l atch connector.
I t has control s for focusi ng and i mage adjustment. The vi ewer i s bat t ery operated.
The battery provides up to 30 mi nutes of cont i nuous use and can be recharged.
The LMA-CTrach i s avai l abl e in si zes 3, 4, and 5 and is reusabl e up to 20 t i mes
(361).

View Figure

Figure 17.12 The LMA-CTrach. It has two built-in
fiberoptic channels, one to convey light from and the other
to convey the image to the viewer. The monitor (viewer) is
attached to the LMA-CTrach via a magnetic latch
connector.

Use
The LMA-CTrach i s l ubri cat ed and i nsert ed si mi l ar t o the LMA-Fast rach wi t hout the
vi ewer att ached (361). An ant if ogging sol uti on shoul d be appl i ed to t he opt ical l ens.
Af ter the LMA has been i nsert ed, t he ai rway secured, and the pat ient venti l ated, t he
vi ewer i s swi t ched ON and at tached. A real -ti me i mage of t he larynx i s then
di spl ayed. I f posi t i oni ng is not sati sf act ory, vari ous maneuvers can be perf ormed to
i mprove the view (361). Af ter a satisf actory gl ot ti c aperture i mage i s achi eved, t he
t racheal tube i s advanced and vi ewed as i t enters the t rachea. Once t he pat i ent i s
i ntubated, the vi ewer i s detached and t he l aryngeal mask removed, l eaving t he
t racheal tube i n pl ace.
Evaluation
The LMA-CTrach has poorer i mage qual i t y than a f lexi ble f iberopti c endoscope. I n
contrast to the vi ew t hrough a l aryngoscope, t he vi ewer provides vi sual i zat ion f rom
t he undersi de of the t racheal tube. I ts advantages incl ude the abi l i ty to al ign the
LMA out l et wi th t he larynx and a hi gh f i rst intubati on at t empt success rate wi th
mi nimal neck movement. As wi t h t he LMA-Fastrach, the LMA-CTrach cannot be
used easi l y in t he pat ient wi th a l imi ted mouth openi ng.
Tracheal i ntubat i on was successful at t he f i rst or second attempt in more than 96%
of pati ents, higher t han bl i nd intubat ion via t he LMA-Fast rach (361,362). The vi ew
may be obstructed by secret ions, l ubricant , or bl ood. I t has proved usef ul duri ng
awake intubati on i n the presence of an unstabl e cervi cal spi ne (363).
LMA-ProSeal
Description
The LMA-ProSeal (LMA-PROSEAL, PLM) (Fi g. 17.13) has f our mai n parts: the cuf f ,
i nf l at i on l i ne wi th pi l ot bal l oon, ai rway t ube, and drai n (gastric access) tube
(364, 365,366,367). Al l components are made f rom si l i cone and are l atex-f ree. I t i s
avai l able i n six si zes (Tabl e 17.5). St udi es i ndi cate that the si ze 4 is pref erabl e f or
P. 475

most adul t women and the size 5 f or most adul t men (368,369).

View Figure

Figure 17.13 LMA-ProSeal. Note the
integral bite block.

TABLE 17.5 LMA-ProSeal
LMA
Size
Patient
Size (kg)
Maximu
m Cuff
I nflation
Volume
(mL)
Maximu
m Gastric
Tube Size
(French)
Maximu
m
Fiberopti
c Scope
Size (mm)
Length
of Drain
Tube
(cm)
Largest
Tracheal
Tube (I D in
mm)
1.
5
5
to
10
7 10 18.
2
4.0
uncuffe
d
2 10
to
20
10 10 19.
0
4.0
uncuffe
d
2.
5
20
to
30
14 14 23.
0
4.5
uncuffe
d
3 30
to
50
20 16 26.
5
5.0
uncuffe
d
4 50
to
70
30 16 4 27.
5
5.0
uncuffe
d
5 70
to
10
0
40 18 5 28.
5
6.0
cuffed
ID, internal diameter.

The ai rway (breathi ng, vent i l ati on) t ube of the LMA-ProSeal is shorter and smal ler
i n diameter than that of t he LMA-Classi c and i s wi re rei nf orced, whi ch makes i t
more fl exi bl e. There i s a l ocati ng strap on the anteri or di stal tube to prevent the
f inger sl i ppi ng of f the tube and to provi de an i nsert i on slot for t he i nt roducer t ool .
An accessory vent under t he drai nage t ube i n the bowl prevents secreti ons f rom
pooli ng and acts as an accessory venti l ati on port . The LMA-ProSeal has a deeper
bowl than the LMA-Cl assic and does not have aperture bars. There i s a bi t e bl ock
bet ween t he tubi ngs at the l evel where the teeth woul d contact the devi ce.
The drai n (drai nage, esophageal drai n) t ube i s paral lel and l ateral to t he ai rway
t ube unti l i t enters t he cuf f bowl , where i t conti nues to an openi ng i n the ti p that i s
sl oped ant eri orl y (Fi g. 17. 14). When the LMA-ProSeal i s correct l y posi t i oned, the
cuff t i p l i es behi nd t he cricoid cart i l age at the ori gi n of the esophagus. I t al lows
l i quids and gases to escape f rom t he stomach, reduces the ri sks of gastri c
i nsuf f lat i on and pulmonary aspi rati on, al l ows devices to pass i nto t he esophagus,
and provides informati on about t he LMA-ProSeal posi t ion. The drai n tube i s
designed t o prevent t he epi gl ot ti s f rom occludi ng the ai rway tube, el i mi nati ng the
need f or ai rway bars (368). A gast ri c tube, Doppl er probe, thermometer,
stet hoscope, or medi cati on can be passed i nt o the esophagus t hrough t he drainage
port (370,371,372,373,374). A pl asti c support i ng ri ng around the di stal drai n tube
prevents the tube f rom col l apsi ng when t he cuf f i s inf l ated.

View Figure

Figure 17.14 Patient end of LMA-ProSeal. The drain tube
continues to an opening in the tip.

The LMA-ProSeal has a second dorsal cuf f (Fi g. 17.15). Thi s pushes the mask
anteriorl y to provi de a bet t er seal around the gl ot ti c aperture and hel ps to anchor
t he devi ce i n pl ace (367). The dorsal cuf f i s not present on si zes 1
1
/
2
to 2
1
/
2
. The
cuff i s sof ter than that on an LMA-Cl assi c. The vent ral cuff i s larger proxi mal l y to
i mprove the seal .
A si l i cone-coated mal leabl e metal introducer t o f aci l i t ate pl acement of t he LMA-
ProSeal is avai lable (Fi g. 17. 16). I t has a curved, mal l eabl e si li cone-coated bl ade
P. 476

wi th a gui di ng handl e. The di stal end fi ts i nt o the l ocati ng st rap, and the proxi mal
end f i ts i nto t he ai rway t ube.

View Figure

Figure 17.15 Posterior of the LMA-ProSeal, showing the
dorsal cuff.


View Figure

Figure 17.16 Metal introducer used to facilitate placement
of the LMA-ProSeal.

Insertion
Insertion Methods
I t i s recommended t hat t he LMA-ProSeal cuf f be def l ated i nt o a wedge shape, as
wi th t he LMA-Classi c. The pati ent should be i n the sni f fi ng posi ti on (l ower neck
f lexion and head extensi on). I t may be necessary t o bri ef l y rel ease cri coi d pressure
t o al l ow the LMA-ProSeal to pass (375).
Introducer Technique
The t ip of the metal i nt roducer is i nsert ed i nto t he st rap at the top of the cuf f . The
ai rway and drai nage t ubes are f ol ded around the int roducer bl ade and i nt o matchi ng
sl ots on ei ther si de of t he introducer. Lubri cant should be pl aced on the posteri or
t i p. The ti p i s t hen pressed agai nst the hard pal ate and maneuvered to spread the
l ubricant al ong the hard pal ate. I f the pal ate i s hi gh, a sl i ghtl y l at eral approach may
be needed. The cuff i s then sl i d i nward, keepi ng pressure against t he pal ate.
As the LMA-ProSeal i s inserted, the i nt roducer is kept cl ose to the chi n. The cuf f
shoul d be observed t o make cert ai n that i t has not fol ded over. The i ntroducer i s
swung inward i n a smoot h ci rcular movement. The jaw can be pul led downward by
an assi stant or pushed downward wi th t he middl e f inger unti l t he cuf f has passed
t he teeth, but the j aw shoul d not be hel d wi del y open, because this may cause the
t ongue and epi gl ot ti s to drop downward, bl ocki ng the mask's passsage. The LMA-
ProSeal is advanced unt i l resistance i s f el t . The nondomi nant hand shoul d be used
t o stabil i ze the ai rway t ube as the introducer i s removed by foll owi ng t he curvature
backward out of the mouth, taki ng care t o avoid damage to the teeth (367). The bi te
bl ock shoul d be at the teet h (376).
I nserti on i n pat ients wi t h a stereotact i c f rame or neck col lar i s probabl y best
perf ormed wi t hout t he i nt roducer t o increase maneuverabil i t y (366).
Digital Method
The di gi t al met hod f or i nsert i on i s si mil ar t o the i nt roducer method except t hat t he
t i p of the i ndex f i nger i s pl aced at the j uncti on of t he cuff and the t wo tubes. As t he
i ndex f i nger passes int o the mouth, the f i nger j oi nt i s extended and t he LMA-
ProSeal is pressed backward toward t he other hand that exert s counterpressure to
mai ntai n t he snif f i ng posi t i on (377). Dependi ng on pati ent and user f inger si ze, the
f inger may need to be i nsert ed to i ts f ul lest ext ent bef ore resi stance i s
encountered. The nondomi nant hand shoul d be used t o stabi l i ze the LMA as the
f inger i s wi t hdrawn.
The t humb may be used to ai d i nserti on when i t i s di ff icul t to get access t o the
pati ent f rom behi nd. The t humb i s inserted i nt o the strap. As the thumb enters the
mouth, t he f ingers are st retched f orward over the pati ent ' s face. The thumb i s
advanced to i ts f ul l est extent. The pushing acti on exert ed by t he thumb agai nst the
hard pal ate serves t o press the head i nto extensi on (377). A l ateral approach is
requi red more f requent l y wi t h t hi s method (366).
Guided Method
Wi th this t echnique, a l ubricated stylet, bougi e, f i beropt ic endoscope, sucti on
catheter, l i ghtwand, or gast ric t ube i s f i rst pl aced t hrough the drain t ube
(366, 378,379,380, 381, 382,383, 384, 385,386, 387,388,389,390,391). The pati ent end
of t he device is t hen i nsert ed i nto the esophagus under l aryngoscopi c or fi berscopi c
gui dance. The bougie shoul d be poi nt ing posteri orl y, opposi te t o when i t i s used f or
i ntubat ion. The LMA-ProSeal is t hen advanced i nto pl ace over the device. Thi s
method avoi ds fol di ng the ti p backward. I t i s more successful and l ess t raumati c
t han usi ng t he introducer t ool or di gi tal methods (381, 385, 388,392). Thi s method
has been used for pat ients wi th known di ff icul t ai rways (393,394), af ter fai l ed
posi t i oni ng of an LMA-Fl exi bl e (395), and to exchange an LMA-ProSeal (396).
Cuff Inflation
Af ter the LMA-ProSeal has been i nserted, the cuf f shoul d be i nf l ated wi t h enough
ai r t o achi eve an i nt racuf f pressure of up to 60 cm H
2
O. Duri ng i nserti on and cuff
i nf l at i on, t he f ront of the neck shoul d be observed to see i f the cricoi d cart i lage
moves forward, i ndi cati ng that the mask has correct l y passed behi nd i t. The cuf f
volume requi red f or the LMA-ProSeal to f orm an ef fective seal wi th t he respi ratory
t ract is l ower than f or t he LMA-Cl assi c (397). In f act , an adequat e seal can be
obtai ned i n most pati ents wi th no ai r i n the cuff ; however, t he cuf f shoul d be
i nf l ated wi th at l east 25% of t he maxi mum recommended vol ume to ensure an
ef fective seal wi t h t he gastroi ntest inal t ract (398).
Tests after Insertion
A smal l amount (1 to 2 mL) of water-based gel or a soap bubbl e shoul d be pl aced
on the end of the drai nage tube that prot rudes f rom the mouth and posi t ive
pressure appl ied to the ai rway tube (399,400, 401,402,403). If the LMA-ProSeal is
properl y placed, there shoul d
P. 477

be a sl i ght up/down movement of the lubri cant/soap. The soap bubbl e may move
when t he l ubricant gel does not (404). I f there i s no movement or t he bol us i s
ej ected, the mask may not be correctl y pl aced.
The drai nage t ube shoul d be test ed for patency. Thi s can be done by passi ng a
gastri c tube, a f l exi bl e endoscope, or a l i ghted styl et t hrough the drai nage tube
(405, 406). Easy passage i ndi cates correct posi t ioning; di ff i cul ty suggests t hat t he
mask shoul d be reposi t ioned, even i f venti l ati on i s sat isfactory.
The suprasternal notch t ap t est i nvolves tappi ng the suprasternal notch or cricoi d
cart i l age and observi ng si mul taneous movement of the soap bubbl e at the proxi mal
end of the drai nage tube (366,400). However, t hi s can produce both f al se posi ti ve
and f al se negati ve resul ts (407).
Proper LMA-Proseal posi ti oni ng can also be detected by inserti ng a l i ghted st yl et
(406). I f the t ip i s folded over, t he st yl et wi l l meet resi stance 1 to 2 cm f rom the t i p
of t he drai n t ube.
Insertion Problems
Several mal posi ti ons for the LMA-ProSeal have been descri bed, i ncl udi ng
i nsuf f ici ent depth, the t i p i nsert ed into t he gl ott i s, the ti p fol ded backward, and
severe epi gl ott ic downf ol ding (408,409).
I f the LMA-ProSeal is i nsert ed to an i nsuff i ci ent depth, there wi l l be a poor seal . If
a bubble of ai r is seen or t he bol us of gel i s eject ed when t he lungs are i nf l ated
wi th l ess t han 20 cm H
2
O, the respi ratory and gast roi ntest i nal t racts are not
i sol ated f rom one another. I f advancing the LMA-ProSeal does not correct the
probl em, i t shoul d be removed and rei nserted.
I f the LMA-ProSeal has entered t he vesti bul e of the l arynx, vent il at i on may be
obstruct ed and gas may leak up the drai nage tube or cause the gel i n the drai n
t ube to move up and down wi t h t he cardi ac rhyt hm (401,403). Pressure on the chest
l eadi ng to bubbl e format i on conf i rms that t he laryngeal vesti bul e has been ent ered
(409). Advanci ng t he mask deeper wi l l exacerbat e the obst ructi on. The mask shoul d
be removed and rei nserted (377).
I f the LMA-ProSeal ti p folds backward, the drai n tube wi l l be pinched of f , leavi ng
t he upper esophageal sphi ncter open (410,411,412,413). Aspi rati on of gast ri c
contents secondary to t his mal posi ti on has been report ed (414). The l ubri cant /soap
bubbl e at the end of the drain tube wi l l not move, even wi t h gentl e tappi ng on the
suprasternal notch (399,400). This mal posi ti on may be associ ated wi th resi stance
t o i nsert i on, unexpectedl y hi gh i nf l ati on pressures, and the bi te block porti on
prot ruding f rom the mouth. I nabi l i t y to pass a gast ric tube f reel y to t he t ip of the
drai n t ube conf i rms the mal posi ti on. Several t echni ques may be used to correct the
si tuat ion, i ncl udi ng reinserti on wi th a lateral approach; reinserti on wi t h the drai nage
t ube st if f ened by a gastri c t ube, bougi e, or st yl et ; bougi e-gui ded rei nserti on; and
sweepi ng a f i nger behi nd t he cuf f (366).
Severe epiglot t ic downf ol di ng occurs when the epi gl ot ti s is dragged inferi orl y and
compl etel y covers t he gl ot ti c i nlet. To correct thi s probl em, the LMA-ProSeal shoul d
be reinserted wi t h t he head and neck in a more ext reme snif f i ng posi t i on, wi t h a j aw
t hrust appli ed or wi t h the epigl ot t is el evated by usi ng a laryngoscope (366).
Inserting a Device through the Drain Tube
The devi ce to be i nsert ed through the drai n tube shoul d be wel l l ubri cat ed and
passed sl owl y and careful l y, not f orced. Warmi ng t he device may f aci l i t ate passage
(415). Some resi stance may be f el t where the drai n tube angulates (416). I t may be
hel pf ul to use back-and-f ort h moti ons whi l e i nserti ng a gastric t ube t o advance
l ubricant i nto t he curved segment and to ease passage through thi s porti on of the
drai n t ube (417). I nabi l i t y t o pass a gastric tube i ndi cates mask mi splacement
(407).
Sucti on shoul d not be appl ied to the end of t he drain tube as t he LMA i s bei ng
i nsert ed, because thi s may cause the drain t ube to col l apse and i nj ure the upper
esophageal sphi ncter. Sucti on shoul d not be appl i ed t o a gast ri c tube unt i l i t has
reached the stomach. The gast ri c tube may be used t o rei nsert the LMA-ProSeal if
i t becomes di spl aced (380). The drain t ube shoul d not be clamped.
A gast ric tube i nserted through t he LMA-ProSeal can be converted to a nasogast ric
t ube (418).
Tracheal Intubation through the LMA-ProSeal
Tracheal i ntubat i on through the LMA-ProSeal requi res a l ong narrow t racheal tube
or an ai rway exchange cat het er (419). Af ter the LMA-ProSeal is removed, a l arger
t ube can be substi tuted, if necessary.
Use
The LMA-ProSeal can be used f or both spontaneous and cont roll ed venti l ati on, but
i s more sui ted to cont rol l ed vent i lati on (409, 420). The seal ing pressure is hi gher
t han wi th t he LMA-Cl assi c i n adul t and pedi at ri c pat i ents, making i t a bet t er choice
f or si tuati ons where higher ai rway pressures are requi red, where bet ter ai rway
protect ion i s desi rabl e, and for surgi cal procedures i n whi ch i nt raoperat ive gast ri c
drai nage or decompressi on is needed
(364, 365,397,398, 411, 413,421, 422, 423,424, 425,426,427,428,429,430,431,432,433,
434,435,436,437,438,439,440,441,442). Case reports show no aspi rat ion of gastric
contents despi t e regurgi tati on or vomi ti ng unl ess the LMA-ProSeal is mal posi ti oned
(414, 436,443,444, 445, 446,447, 448, 449,450, 451,452,453,454). However, aspi rati on
has been reported wi t h malposi ti oni ng (455).
I t may be easier to pl ace t he LMA-ProSeal than the LMA-Cl assi c duri ng manual i n-
l i ne neck st abi l i zati on (424). I t has been used i n cases of known di ff icul t ai rway
(428) and has been successful l y used af t er f ai l ure wi t h an LMA-Classi c (375,427).
The LMA-ProSeal may be useful in cases where i t is i mportant to avoi d ai rway
t rauma, as i t exerts lower pressures agai nst t he pharyngeal mucosa than t he LMA-
Cl assic (397). However, ai rway t rauma as evi denced by
P. 478

bl ood on t he device af ter removal i s higher f or t he LMA-ProSeal t han f or the LMA-
Cl assic (409).
The LMA-ProSeal has been found to be safe f or use i n an MRI uni t , but imaging
quali t y may be compromi sed, dependi ng on the pul se sequence that is used and
whether the area of int erest i s near the LMA (456).
Problems with the LMA-ProSeal
The LMA-ProSeal is l ess sui t able as an i ntubati on devi ce t han t he LMA-Fast rach
because of the narrower ai r way t ube. The fi berscope and t racheal tube si zes that
can be accommodated by the LMA-ProSeal are given i n Tabl e 17.5. The hi gh
resi st ance associated wi th t he smal l er l umen may make i t l ess sui t abl e for use wi th
spontaneousl y breathing pat ients than ot her devi ces (457).
The LMA-ProSeal may be somewhat more di ff icul t and t ake sl i ght l y l onger to i nsert
t han the LMA-Cl assic i n adul ts, al though overal l success i s equival ent
(364, 365,397,408, 411, 413,421, 422, 432,433, 458). The i nci dence of i nt raoperative
compl i cati ons and postoperati ve sore throat are si mi lar. I n chi ldren, the ease of
i nsert i on i s si mi l ar t o the LMA-Cl assic (434,435,437,459). The LMA-ProSeal
requi res a greater dept h of anest hesi a for inserti on t han does t he LMA-Cl assi c
(460).
The LMA-ProSeal can cause ai rway obst ruct i on af ter i nserti on, ei ther by
compressi ng the supragl ot ti c and gl ot ti c st ructures or by cuf f i nfolding (462,463).
Removing ai r f rom the cuf f or placi ng the pati ent i n the sni ff i ng posi t ion may rel ieve
t he obst ruct ion.
Parti al upper ai rway obst ructi on duri ng spontaneous vent i l at ion may resul t i n
aspi rat ing ai r t hrough t he drai n tube i nt o the esophagus (404,463). Esophageal
i nsuf f lat i on can occur simul taneousl y wi t h venti ng f rom the drai nage t ube duri ng
posi t i ve pressure venti l ati on wi th mal posi t i on (464,465). Thi s may resul t i n
i nadequate venti lati on.
I t may not be possi bl e to i nsert a gast ri c tube i n some pati ents (466,467). Thi s may
be due to sel ecti on of too large a t ube, i nadequate l ubri cat ion, usi ng a cooled
gastri c tube, cuf f overi nf l ati on, or mal posi t ion (415).
The LMA-ProSeal is rel ati vel y cont rai ndi cated f or i nt raoral surgery because i t
cannot be moved easi l y around the mouth, the drai nage tube i s vul nerabl e to
occl usi on, and the l arger proxi mal cuf f could i nt erf ere wi t h the surgi cal fi el d (365).
The LMA-ProSeal has a short er l if e span than the LMA-Classi c (468)
Using the LMA Family
An LMA of the chosen si ze pl us one si ze smal ler and l arger shoul d al ways be
i mmedi atel y avai lable. The syri nge used to i nf lat e the LMA shoul d contai n onl y ai r.
I nject ing organic subst ances such as propof ol f rom a previ ously used syri nge may
damage the LMA (469).
Preuse I nspecti on
Visual Inspection
The f i rst step i s to exami ne the t ube. The ai rway tube shoul d not be di scol ored, as
t his woul d prevent seei ng fl ui ds that may enter the tube. There should be no cuts or
t ears i n the tube, and t he spi ral wi res shoul d not be ki nked. The rest of the LMA' s
external surface should be exami ned for damage such as cuts, tears, scratches, or
f oreign part i cles.
The i nt eri or shoul d be f ree f rom obstruct i on or f oreign part icles. The LMA-Fl exi bl e
shoul d be exami ned to make cert ain t hat t he reinf orci ng wi re i s whol ly contai ned
wi thi n t he wal l of t he tube.
The t ube shoul d be f l exed up to, but not beyond, 180. Ki nki ng should not occur.
Bendi ng the t ube beyond 180 could cause permanent damage.
The next test i s to exami ne the mask apert ure. The bars shoul d be gent ly probed to
make cert ai n that they are not damaged and t he space bet ween them is f ree f rom
part iculate mat ter. I f the drai n tube i n the LMA-ProSeal bowl i s torn or perf orated,
t he LMA should not be used.
The connector should f i t ti ght l y i nto the outer end of t he ai rway tube. I t shoul d not
be possi bl e to remove i t easi l y. The connect or shoul d not be t wi sted. I f the
connector has cracks or surf ace i rregul ari t ies, i t shoul d not be used.
Deflation/Inflation
The next step i s to wi thdraw ai r f rom t he cuf f so t hat t he wal ls are fl at tened against
each other. Excessi ve f orce shoul d be avoided. The cuf f shoul d not reinf l at e. The
syri nge shoul d be removed f rom the i nf l ati on valve and the cuf f checked t o make
cert ai n t hat i t remai ns def l ated. If i t rei nf lates, t here i s a faul t y val ve or l eaki ng
cuff . An LMA cuf f wi th a hol e may not rei nf late af ter the ai r had been removed
(470).
The next step i s to i nf l ate the cuf f wi t h 50% more ai r t han t he recommended
maxi mum inf l at ion vol ume (Table 17.6).
The cuff should hold t he pressure for at l east 2 mi nutes. Any herni at ion, wal l
t hinni ng, or asymmet ry i s an i ndi cat i on to di scard the LMA. The bal loon shoul d be
el l i pti cal , not spheri cal or i rregul arl y shaped. Excessi ve pi l ot ball oon wi dt h
i ndi cates weakness and i mmi nent rupture. Fai lure to perf orm thi s test may miss
probl ems wi th t he cuf f (467,471).
Mask Preparation
The cuff should be f ul l y defl ated wi t h a dry syri nge to f orm a f lat oval di sc (Fi g.
17.17) Thi s can be done by pressi ng t he hol l ow side down agai nst a clean, hard,
f lat surface. The defl ated cuff shoul d be wri nkle-f ree.
A cuf f -def l ati ng t ool i s avai l abl e f rom the manuf acturer (Fi g. 17.18). Thi s devi ce wi l l
provi de a superi or and more consi stent shape than ei ther hand mani pul at i on or f ree
defl ati on but does not of f er any benef i ts in
P. 479

t erms of residual volume (472). The use of thi s devi ce wi l l l engt hen t he cuf f l i f e
(473).
TABLE 17.6 Maximum Test Cuff Inflation Volumes
Size LMA-Classic or LMA-
Unique (mL)
LMA-Flexible
(mL)
LMA-Fastrach
(mL)
LMA-ProSeal
(mL)
1 6
1.5 10
2 15 15
2.5 21 21
3 30 30 30
4 45 45 45 45
5 60 60 60 60
6 75 75

Lubri cat i on should be appl i ed to the posteri or cuf f surface cuf f j ust before i nserti on,
t aki ng care to avoi d gett i ng l ubri cant on t he anteri or (bowl ) surf ace. The
manuf acturer recommends water-sol ubl e j el l y and does not recommend the use of
analgesi c-cont ai ni ng gel s or sprays, because thi s may del ay t he return of protect i ve
ref l exes and may provoke an al l ergi c react ion. Whi le some studies show t hat
l ubricati on wi th l idocai ne gel or spray wi l l resul t i n a l ower i ncidence of retchi ng
and coughing on emergence (87,474), another study showed i ncreased i ntra- and
postoperati ve probl ems (475). Lubri cants or sprays that cont ain si l i cone may cause
t he mask t o sof ten and swel l .

View Figure

Figure 17.17 The laryngeal mask ready for insertion. The
cuff should be deflated as tightly as possible, with the rim
facing away from the mask aperture. There should be no
folds near the tip. (Courtesy of Gensia Pharmaceuticals,
Inc.)

Anesthetic I nduction
I nserti on of the LMA requi res suf f i ci ent general or topical anesthesia t o obtund the
ai rway ref l exes. A dept h si mi l ar t o t hat necessary f or i nserti ng an oropharyngeal
ai rway but not as deep as is needed f or t racheal i ntubati on i s requi red (476).
Absence of a motor response t o a jaw t hrust i s a rel i abl e method for assessi ng the
adequacy of anesthesi a f or LMA inserti on (477). Greater depth is needed f or
i nsert i ng the LMA-ProSeal than f or t he LMA-Cl assi c (460).
Awake Placement
The l aryngeal mask can be i nserted i n an awake pati ent f ol l owi ng t opi cal
anesthesi a of the upper ai rway and/ or nerve bl ocks
(99,100,135,248,478,479,480,481,482,483). Mask i nserti on shoul d be coordi nated
wi th swal l owi ng. It may be helpf ul to part i all y i nf l ate t he cuf f to si mul ate a bol us of
f ood (484).
Cuff Inflati on and Assessing Positi on and Functi on
The cuff should be i nf lat ed to a pressure of approxi matel y 60 cm H
2
O (485,486). A
cuff pressure gauge i s recommended for proper i nf l ati on pressure. Cuff pressure
can be est imated by f eel ing the t ensi on i n the pil ot bal l oon. A spheri cal pil ot
bal l oon i s an indicat ion that t here is too much gas i n the cuf f .
The cuff should be i nf lat ed over 3 to 5 seconds wi t hout hol di ng the t ube unless the
posi t i on is obvi ousl y unstabl e (e. g., in edent ulous pat i ents wi t h sl ack t issues). This
usual l y causes sl i ght upward movement of the ai rway tube, and a sl i ght bul ging at
t he f ront of the neck i s commonl y seen. There shoul d be a smooth oval swel l ing i n
t he neck and no cuf f vi si bl e i n the oral cavi ty.
The recommended maximum i nf l at i on vol umes are gi ven i n Tabl e 17.7. I n practi ce,
i t is rarel y necessary to
P. 480

use t he f ul l vol ume (30,485,487,488). Using greater-than-recommended vol umes
wi l l not i mprove the seal agai nst the l arynx and may worsen i t (194). A rati onal
approach i s to inf l at e the mask wi t h hal f the maxi mum i nf l ati on vol ume and to
determine t he oropharyngeal leak pressure, addi ng more ai r i f necessary. Cuf f si ze
i s probabl y more i mportant than i nf l at ing vol ume i n determi ni ng the seal , so
upsi zing t he LMA may provi de a bet ter seal than addi ng more ai r to the cuf f of a
smal l er LMA (10,16, 489, 490).

View Figure

Figure 17.18 Cuff-deflating device for the Laryngeal Mask
Airway. A: The laryngeal mask is inserted into the device.
The cuff is deflated by using a syringe. At the same time,
the device is compressed. B: After cuff deflation, the LMA
is ready for insertion.

I f posi t ive-pressure vent i lati on is to be used, t he leak pressure should be greater
t han 20 cm H
2
O (30 cm H
2
O wi t h t he LMA-ProSeal ). If spontaneous respi rati on i s to
be used, t he l eak pressure shoul d be greater than 10 cm H
2
O. This i s the
approxi mate pressure of f l ui d at the posterior pharyngeal wal l i f t he oral cavi ty i s
f looded (491). Unt i l spontaneous respi rat i on has resumed, i t may be hel pful to
occl ude the nose and seal t he mouth around t he tube to al l ow posi ti ve-pressure
venti l ati on (492).
The ai rway seali ng pressure i s det ermi ned by observi ng the pressure gauge in the
breat hi ng system as the bag i s squeezed and the pressure i ncreases. Several
methods can be used t o determine t he l eak pressure (493, 494). A st ethoscope can
be pl aced just l ateral to the thyroi d cart i l age. Anot her method i s to l i sten over t he
mouth for a noi se when the bag i s squeezed. Carbon di oxi de may be detected by
pl aci ng t he sampl e l i ne i n the oral cavi ty. Another method i s determi ni ng a steady
ai rway pressure af ter closi ng the adjustabl e pressure li mi ti ng (APL) val ve i n the
ci rcle system.
I t may be possi ble to improve the seal by addi ng more ai r t o t he cuff (if the
maxi mum recommended vol ume has not been i nj ected) or by f lexi ng or rotati ng the
head and neck sl i ghtl y (222, 495, 496). The l eak pressure wi l l be higher i f the head
and neck are fl exed or rotat ed (222, 433, 497,498). Higher pressures may be
achieved by appl yi ng pressure on the f ront and/or si de of t he neck, by appl yi ng
conti nuous f orward pressure on t he LMA, or by l i f t i ng the handl e of the LMA-
Fastrach (499, 500,501, 502, 503,504).
I ndi cat i ons that t he LMA is properl y posi t ioned incl ude normal breath sounds, chest
movements, pressure-vol ume l oops and volume moni tori ng not showi ng a l eak, and
carbon dioxi de wavef orms wi t h posi t ive-pressure vent i l at i on. I f the pat ient is
breat hi ng spontaneousl y, normal reservoi r bag excursi ons and absence of si gns of
obstruct i on are i ndi cati ons of proper
P. 481

pl acement (506). A f i berscope or ri gid endoscope can be i nsert ed t hrough the LMA
t o conf i rm i ts posi ti on and rul e out ai rway obstruct i on (73,79,109,506,507). X-ray or
MRI can also be used t o conf i rm the posi ti on (75,508). An esophageal detector
device can be used (509,510), al though i ts ut i li ty has been quest i oned (511).
TABLE 17.7 Maximum Cuff Dimensions
Mask
Size
Air Volume
(mL)
Maximum Bulge of
Cuff Tip (mm)
Maximum Bulge of
Wide End of Cuff (mm)
Maximum Transverse
Diameter of Cuff (mm)
1 6 7.8 8.6 26.3
1.5 10 9.5 10.2 32.6
2 15 11.5 13.0 39.0
2.5 21 13.0 14.5 45.0
3 30 14.8 16.6 51.2
4 45 17.0 19.0 58.5
5 60 21.1 22.4 68.3

I f the ai rway i s obst ructed, the cause may be incorrect mask posi ti on, a downf ol ded
epi gl ot ti s, a cl osed gl ot ti c sphi ncter, or an overi nfl ated cuf f . In most cases,
removi ng and rei nsert ing t he mask wi l l el imi nate the obst ructi on. Anot her t echni que
i s to l i f t the ant eri or neck st ructures by usi ng a gloved hand i nserted i nt o the
mouth, def l at e the cuff , and rotat e the mask 360 (512). I n some cases, t he
epi gl ot ti s may be st raightened di gi tal l y (513). Jaw mani pul ati on or reposi ti oning the
head usuall y does not rel i eve ai r way obstruct i on. Removi ng ai r f rom t he cuff may
be helpf ul (514). I f despi te these eff orts sati sf actory vent il at ion cannot be achieved,
t he devi ce shoul d be wi t hdrawn and rei nsert ed or a di ff erent si ze LMA or tracheal
t ube shoul d be used.
Fixation
A bi te bl ock or rol l of gauze shoul d be i nsert ed i nto the mouth besi de the tube t o
prevent the pat ient f rom bi ti ng the t ube and to i mprove stabi l i ty. Thi s i s not
necessary wi t h t he LMA-ProSeal . Vari ous other devi ces have been used
(515, 516,517,518). An oropharyngeal ai rway shoul d not be used, because both i t
and the LMA are desi gned t o be pl aced i n the mi dl i ne, and t he ai rway ti p mi ght
compromi se the LMA cuf f or cause tube compressi on (519). Al so, an oropharyngeal
ai rway may not prevent t he tube f rom bei ng bi tt en (121, 520).
The t ube shoul d be secured wi t h t ape, taki ng care that i t does not become twi st ed.
Thi s can be accompl i shed by af f i xi ng the t ape f i rst to the maxi l l a, wi ndi ng over the
cephal ad si de of the tube, and down around t he caudal si de to f ix the tube and bi te
bl ock f i rml y t o each other and t o the opposi t e maxi l l a (521). Further securi t y can be
provi ded by tapi ng f rom zygoma to zygoma under t he mandi bl e (522) or around the
neck (523,524). A tracheal tube hol der may be used (525). Ot her f i xat ion methods
have been descri bed (526,527). The f ixat ion method shoul d not obst ruct the
surgery. A suture around a tooth may be used i f t ape wi l l be i n the way.
Bendi ng the t ube against i ts natural curvat ure may cause i t to become di sl odged or
ki nk, unl ess t he LMA-Flexi bl e i s used. Tracti on f rom the breathi ng system shoul d
be avoi ded, and several met hods t o achi eve t hi s have been suggested (527, 529).
Intraoperati ve Management
During surgery, ai rway pat ency and correct LMA ori entat i on should be veri f i ed at
regul ar i nterval s. The pati ent ' s upper abdomen shoul d be peri odi cal l y observed for
si gns of di stent ion and epi gast ric auscul tati on perf ormed. A li ghter l evel of
anesthesi a than woul d be requi red i f a tracheal t ube were used is usual ly possi bl e.
I f laryngospasm, wheezi ng, swal l owi ng, coughi ng, st rai ni ng, or breath hol di ng
occurs, anesthesi a shoul d be deepened or muscl e rel axants admi nistered. An
aerosol can be admi nistered by using an LMA (530).
Ni trous oxide and carbon di oxide can dif f use i nto the cuf f , increasi ng i ntracuf f
pressure and vol ume
(198, 199,531,532, 533, 534,535, 536, 537,538, 539,540,541,542,543,544). Cuf f vol ume
i ncreases less wi t h the LMA-Unique than wi t h t he LMA-Cl assi c (198). The i ncrease
i n vol ume may cause ai rway obst ructi on (514). Infl at i ng the cuff wi t h ni t rous oxi de
wi l l avoi d this i ncrease (545,546).
The manufacturer recommends t hat cuf f pressure be checked periodical l y wi th a
pressure gauge, transducer, or other device (Fi g. 19.29) and adjusted t o keep i t at
approxi matel y 60 cm H
2
O. The pi lot bal l oon shoul d f eel compl i ant . If the bal l oon
f eel s sti f f or ol i ve shaped, t he pressure may be excessi ve. Others have suggested
t hat the l ogi cal method of control l i ng cuf f pressures during ni t rous oxi de anesthesi a
may be t o take t he j ust seal pressure as a cont rol val ue and wi t hdrawn vol ume t o
mai ntai n val ues cl ose t o thi s pressure (546).
The LMA can be used wi th cont rol l ed (i ncl uding mechani cal ) or spontaneous
venti l ati on. Pat ient outcome has been f ound t o be si mi l ar i n nonparal yzed pati ents
wi th posi tive-pressure venti l ati on or spontaneous breat hi ng (547). If cont roll ed
venti l ati on i s used, the peak i nspi rat ory pressure shoul d be kept bel ow 20 cm H
2
O
(30 cm H
2
O wi t h the ProSeal ). Hi gher pressures may resul t i n a l eak around the
mask, gastric distenti on, and operat ing room pol l ut ion (15, 548,549,550, 551, 552).
Changes i n the vent i l atory patt ern to reduce t i dal volume and usi ng muscle
rel axants may resul t i n a l ower peak pressure. I f hi gher pressures are requi red,
consi derat ion shoul d be gi ven to exchangi ng t he LMA f or a t racheal tube. If cricoi d
pressure i s appl i ed, t he ai rway pressures at which the pati ent i s venti l ated can
of ten be increased t o over 30 cm H
2
O wi t hout gast ri c insuf f l at ion occurri ng (553).
Pressure control vent i l at i on (Chapter 12), wi th or wi t hout PEEP, whi ch i s avai l abl e
on newer anesthesi a venti lators, may be the mode of choice f or cont rol l ed
venti l ati on wi th t he l aryngeal mask because i t al l ows a l ower peak pressure for the
same t i dal volume wi t h l ess leak around the LMA (439,554,555). For pati ents
breat hi ng spontaneousl y, pressure-support venti l at ion i mproves gas exchange and
reduces the work of breathi ng (556,557). The work of breathing can al so be
reduced by usi ng CPAP (558).
A sudden i ncrease i n l eakage, snori ng, or ot her sounds of ten si gnals t he need f or
more muscl e rel axati on, al though ot her causes such as LMA displ acement, l i ght
anesthesi a causi ng gl ott i c cl osure, ai rway obst ruct ion, a leaki ng cuf f , and a
decrease i n l ung compl iance related to the surgical procedure are other possi bl e
causes
P. 482

(559). Adding ai r t o the cuff wi l l not al ways correct a l eak and may make i t worse
by i ncreasing t ensi on i n the cuf f and pushi ng i t away f rom the l arynx (560).
Someti mes, removing some ai r f rom t he cuff wi l l hel p.
I f regurgi t ati on occurs, the f i rst sign may be t he appearance of f l ui d travel i ng up the
LMA tube. Breat h hol di ng or coughi ng may occur. The pati ent should be pl aced i n
t he head-down posi t ion, the breathi ng ci rcui t di sconnected, and the ai rway t ube
sucti oned. I t may not be necessary t o remove t he LMA, al though preparat ions for
t racheal int ubati on shoul d be made and t he pati ent i nt ubated, i f i ndi cated.
I nserti ng a nasogastri c t ube behi nd a non-ProSeal LMA can be ai ded by usi ng a
nasal ai r way or a f lexible endoscope to displ ace the LMA f orward (561).
Emergence from Anesthesi a
I t i s i mportant that the bi te bl ock or rol l of gauze be lef t i n pl ace unt i l the LMA i s
removed to mai ntai n pat ency and prevent damage to t he LMA (562,563). Cuf f
defl ati on shoul d be performed onl y when t he LMA i s removed (564, 565). I f the cuff
remai ns inf l at ed as the LMA i s removed, a greater mass of secret ions wi l l al so be
removed (566), but this techni que increases t he i nci dence of bl ood stai ni ng (but not
sore throat) (567). Taki ng of f a glove that was worn when t he LMA was removed
and i nverti ng i t over the device wi l l minimi ze t he spread of contami nat ion (568).
Keepi ng the LMA i n place duri ng t ransf er t o the post anesthesi a care uni t (PACU)
wi l l maintai n a patent ai rway, whi l e l eavi ng t he anesthesi a provider' s hands f ree f or
ot her t asks. Duri ng recovery, suppl ementary oxygen can be del i vered wi t h the LMA
i n place by usi ng a T-piece or other devi ce
(569, 570,571,572, 573, 574,575, 576, 577,578, 579,580). Wi th t he T-piece, respi rat ion
may be assi sted manual l y by i ntermi t tent l y occl udi ng t he expi ratory l i mb (19).
There i s cont roversy regardi ng the opti mal ti me f or LMA removal . I t shoul d ei ther
be removed wi t h t he pati ent i n a deep l evel of anest hesi a or when f ul l recovery of
ai rway ref l exes has occurred. Leavi ng the LMA i n posi t i on unt il ai rway ref l exes
have recovered and the pat i ent can phonate or open hi s or her mout h on command,
as recommended by the manufacturer, wi l l ensure mai ntenance of a secure ai rway.
The onset of swal l owi ng is a usef ul predi ctor t hat such a level of wakeful ness is
i mmi nent.
The LMA shoul d not be removed duri ng a l ight l evel of anesthesi a. I f swal l owi ng
and cough ref l exes are not present, secretions in t he upper pharynx may f l ood i nto
t he l arynx, provoki ng laryngospasm, coughi ng, or gaggi ng. Removi ng the LMA whi l e
t he pat ient i s anestheti zed or coi nci dent wi t h si gns of rej ecti on (swal l owi ng,
st ruggl ing, and rest l essness) but before t he pati ent responds to commands can
i ncrease t he i nci dence of gastroesophageal ref l ux (581, 582).
Removing the LMA whi l e the pat i ent i s under deep anesthesi a wi l l decrease the
i nci dence of coughi ng, breath holding, and bronchospasm. I t may be hi ghl y
desi rabl e i n some si tuati ons, such as af ter i nt raocul ar surgery. It should not be
perf ormed i n a pat ient known to be di f f i cul t t o i nt ubate. Deep extubati on has been
associ ated wi th ai rway obst ruct ion, regurgi t at i on, and l aryngospasm (563,583).
Damage to the LMA i s l ess f requent when the LMA i s removed under deep
anesthesi a (563).
Most studi es show t hat i n chi l dren, removal when awake may resul t i n a hi gher
i nci dence of ai rway probl ems (l aryngospasm, coughi ng, breath hol di ng,
bronchospasm) compared wi t h removal whi l e deep
(584, 585,586,587, 588, 589,590, 591). However, a si mi l ar or hi gher i nci dence of
ai rway probl ems i n chil dren wi t h deep removal has been reported by some
i nvesti gat ors (589,592, 593,594).
The pati ent should be l ef t undi sturbed, except t o admi nister oxygen and perf orm
moni tori ng, and shoul d not be t urned onto hi s or her si de unless there i s an
i ndi cat i on (such as regurgi tat i on or vomi t i ng) because thi s may cause premature
rej ecti on of the LMA. It i s not necessary to remove secreti ons i n the upper pharynx,
as t hey do not enter t he l arynx provi ded the cuf f is not def l ated pri or t o removal ,
and the LMA is not removed before the pat ient is able to swal l ow eff ect i vel y.
Sucti oni ng through t he LMA shoul d not be performed unl ess there i s evi dence of
gastri c contents i n the tube.
Care and Cleaning
As soon as possi ble af ter use, the reusabl e LMA shoul d be gentl y cl eaned wi t h
warm water and a di lute (8% t o 10%) sodium bi carbonate soluti on unt i l al l vi si bl e
materi al has been removed. The sol uti on of bi carbonate wi l l hel p to di ssolve
secreti ons (23, 239). I f a mil d det ergent i s used, i t shoul d be one that contai ns no
mucous membrane i rri t ants. A pi pe cl eanertype brush should be i nsert ed through
t he di stal apert ure t o cl ean out the shaf t, taki ng care not to damage the bars. The
drai n t ube of the LMA-ProSeal shoul d be cleaned caref ul l y, because i t coul d be
damaged by a sti f f brush (417). The i nf l ati on valve shoul d not be exposed to any
cl eaning sol uti on, because t hi s may cause val ve fai l ure (30). The LMA shoul d be
ri nsed wi t h tap water to remove resi due and t hen dri ed and pl aced in a pouch
(239).
Water shoul d not be al l owed to enter the cuf f . Autoclavi ng an LMA wi t h wat er i n t he
cuff may cause i rreversibl e damage (595). To remove f l ui d f rom t he cuf f wi thout
damagi ng the LMA, the cuff shoul d be empti ed wi th the cuf f uppermost and
manual l y squeezed. A syri nge wi thout a pl unger shoul d be insert ed i nt o the i nfl ati on
valve and the LMA pl aced in a warmi ng closet f or 12 hours at 60C (596, 597).
As much ai r as possi bl e shoul d be removed f rom the cuff shortl y bef ore autocl avi ng
(598, 599). Resi dual ai r
P. 483

wi l l expand in t he heat and may damage the cuff , valve, or pil ot bal l oon
(599, 600,601,602). If desi red, an LMA can be pref ormed i nto a more desi rable
shape by bendi ng i t when i t is packed f or autoclavi ng (603). A red pl ug is suppl i ed
wi th t he LMA-ProSeal (604). Leavi ng the val ve open l ets ai r escape to t he
at mosphere.
TABLE 17.8 Minimum Exposure Time for Steam Autoclaving of Reusable Laryngeal
Mask Airways
Autoclave Wrapped Unwrapped (flash)
Gravity displacement 10 to 15 minutes 10 minutes
Prevacuum 3 to 4 minutes 4 minutes

The LMA can be autocl aved at temperatures up to 135C (275F) (23, 30) (Table
17.8). Hi gher t emperature can cause the tube to become bri t tl e and f ragment. The
LMA shoul d be al l owed t o cool to room temperature af ter steri l i zati on. Autoclavi ng
i mpai rs the bond between the connector and t he tube but not i ts ai r t ightness (605).
The World Heal t h Organi zat ion gui del ines and publ i shed l i terature i ndicate that the
LMA cl eaning and steri li zati on procedures di scussed previ ously are suf f ici ent for
i nact i vat ion of convent i onal pathogens such as bacteri a, fungi , and vi ruses. In
pati ents known or suspected t o have a transmissi ble spongi f orm encephalopathy, i t
i s recommended that the LMA be dest royed af ter use. An LMA-Uni que shoul d be
used i n these cases.
Li qui d chemical agents such as gl utaral dehyde, phenol -based cleaners, i odi ne-
contai ni ng cleaners, or quat ernary ammoni um compounds or ethyl ene oxi de shoul d
not be used t o cl ean or steri l i ze t he LMA. They are adsorbed ont o the si l i cone and
can cause pharyngi tis and l aryngi t is as wel l as short en the LMA l if e
(23,30,239,606).
Life Span
Wi th caref ul use and st ri ct adherence to cl eani ng and steri l i zati on procedures, a
l aryngeal mask ai rway wi l l l ast for a l ong t i me. The recommended maximum number
of uses by the manuf acturer f or t he LMA-Classi c is 40, but up to 200 uses have
been report ed (239, 469, 607,608, 609). Wi th repeated use, there i s a decrease in
el astance, an i ncrease in cuff permeabi l i ty, and a l oss i n strength of t he ai rway
t ube (468, 608, 610). I t may be possi bl e to exchange a malf uncti oni ng i nf lat i on valve
on an LMA (611). The LMA-ProSeal has a shorter l i f e span than the LMA-Classi c
(468).
Dead Space
The dead space associ at ed wi t h the LMA i s l ess than wi t h a face mask but is
great er t han wi th a tracheal tube. The correl ati on between end-ti dal and arteri al
carbon dioxi de is bett er wi th t he laryngeal mask t han wi th the face mask (612,613)
and as accurat e as wi th a tracheal t ube (614, 615,616, 617). The pref erred si te f or
measuri ng end-t i dal carbon di oxi de in chi l dren i s t he l aryngeal end of the shaf t
(618).
Flow Resistance and Work of Breathing
Resistance to breathi ng i s an i mport ant consi derat ion wi t h the LMA because i t i s
f requent l y used wi th spontaneous breathi ng. Whi le t he LMA i tself of f ers l ess
resi st ance than a tracheal tube, total respi rat ory resistance and work of breat hi ng
have been f ound t o be si mi l ar because the l arynx i s not bypassed
(619, 620,621,622, 623, 624). The work of breat hi ng through t he LMA i s simi l ar to
t hat wi th a f ace mask unl ess t here i s di ff i cul ty i n mai ntai ni ng a pat ent ai rway. The
LMA-Fl exi bl e has a smal ler ID and i mposes si gni f i cantl y greater resi st ance t han
ot her LMAs (105,228).
Useful Situations
The LMA has been used for a wi de vari et y of procedures, but i t is probabl y best
sui ted to short cases, making i t especi al l y usef ul f or outpati ent surgery. I t has
proved usef ul f or pati ents who need mul t iple anesthet ics over a short peri od of
t i me. The maxi mum durati on f or whi ch the LMA can be safel y used i s not known. It
has been used for surgical procedures l asting up t o 8 hours (625,626). The
l aryngeal mask has been used wi th l ow-f l ow and cl osed system anesthesi a
(627, 628,629,630).
Difficult Face Mask Technique
For pat ients i n whom mask venti l ati on i s or could be dif f i cul t , such as edentul ous
pati ents or t hose wi th f aci al i nj uri es or a f ragi le nose, those wi t h faci al contours
t hat are not sui ted t o a f ace mask or beards, and pati ents undergoi ng l aser
t reatment of the face, i t may be easi er to mai nt ai n a sat isf actory ai rway wi t h t he
LMA (631). Studi es compari ng LMA use wi t h a f ace mask show f ewer epi sodes of
desaturati on and l ess dif f i cul t y i n mai nt ai ning an ai rway wi th t he LMA
(632, 633,634,635, 636).
The LMA may prove usef ul f or pat i ents wi t h f aci al burns who of ten requi re mul ti pl e
anesthet ics (638). However, i t i s not appropri at e to use the LMA to secure the
ai rway i n a pat i ent wi th upper ai rway burns.
Difficult or Fai led I ntubati on
Laryngeal masks have contri buted greatl y to solving t he di ff i cul t i ntubat ion probl em.
The LMA i s part of the American Soci et y of Anesthesi ol ogi sts' dif f i cul t ai rway
al gori thm, the American Heart Associ at ion advanced cardi ac l if e support course,
and vari ous i nternat ional guidel i nes (638,639, 640, 641,642, 643).
I n si tuati ons where the pat ient cannot be i ntubated, the LMA may be usef ul and
even l i f esaving by usi ng i t ei t her as the pri mary means of mai nt ai ning
P. 484

an ai rway or t o f aci l i tate passage of a t racheal tube
(254, 374,426,427, 430, 636,644, 645, 646,647, 648,649,650,651,652,653,654,655,656,
657,658,659,660,661,662,663,664,665,666,667,668,669,670,671,672,673,674,675).
For thi s reason, i t is recommended that an LMA be i mmedi atel y avai l abl e whenever
a cannot intubate/cannot venti late scenari o i s possi bl e. I n the pati ent whose
t rachea cannot be i ntubated because of unfavorabl e anat omy (but not peri gl ot ti c
pathology), the LMA shoul d be considered as the f i rst t reat ment opti on (110).
The LMA may be usef ul i n pat ients wi th ai rway di stort i on secondary to tumor
(676, 677), l aryngeal f racture (679), congeni t al probl ems
(42,103,479,648,679,680,681,682,683,684,685,686), f aci al i nj uri es (644,687),
hematoma or abscess (688,689), l aryngeal pol yposi s (691), l aryngeal injuri es (683),
supraglott ic edema (657), tonsi l l ar hypertrophy (691,692), osteogenesis i mperf ecta
(694), l i mi ted mouth openi ng (28,118, 267, 694,695), neck mass (267), poor neck
mobi l i t y, and presence of a cervi cal col l ar
(24,95,241,246,255,306,318,694,695,696,697,698,699,700).
The l aryngeal mask has been used both as t he pri mary ai rway and to f aci li tate
i ntubat ion f or pati ents wi th Pi erre-Robi n (42,103,480,679,681,682,684,685,701,702)
and Treacher Col l i ns syndromes (650,704,705,706,707), and other congeni tal
condi ti ons that make intubat ion di f f i cul t (707).
I f the t racheal t ube cuf f i n a di f fi cul t -t o-i ntubate pati ent develops a l eak, i t may be
possi bl e t o el i mi nate the l eak by i nserti ng a l aryngeal mask over the tube, i nf l at ing
t he cuf f , and then seal i ng the proxi mal orif ice (714).
Ophthalmic Surgery
The LMA has been used for procedures on the eye (232,715,716,717, 718,719).
Most studi es have shown t hat i nt raocul ar pressure i s l ower af ter i nserti ng an LMA
t han a tracheal tube (720, 721,722, 723, 724,725,726,727,728,729,730,731).
I ntraocul ar pressure duri ng emergence is usual l y l ower wi t h an LMA (729,732).
Reservati ons have been expressed about use of the LMA i n ocular surgery
(733, 734). The LMA may be dislodged duri ng intraocul ar surgery (728,735, 736).
Thi s can be prevent ed by caref ul f i xat ion and maintenance of an adequat e depth of
anesthesi a and muscl e rel axati on (737). The use of an LMA-Flexi bl e has been
recommended.
Tracheal Procedures
Some pati ents wi t h tracheal stenosi s may be managed by using t he l aryngeal mask
(689, 739,740,741, 742, 743,744, 745, 746,747, 748,749,750), al though f ai l ure in t his
si tuat ion has been report ed (751). The LMA has been used as a bl ocker t o prevent
gas l oss f rom the trachea during a t racheopl ast y (752).
Compression of the trachea by a medi ast inal mass can cause probl ems si mi l ar t o
t racheal stenosis. Bot h medi astinoscopy and t horacotomy have been perf ormed i n
t his si tuat i on wi t h the LMA and spontaneous vent i l at ion (753,754,755). However,
using t he LMA in a pati ent wi t h a mediasti nal mass has been quest ioned (756).
The l aryngeal mask has been used to diagnose l aryngomal aci a and
t racheobronchomalacia i n adul ts and chi l dren (758,759,760,761). However, i ts use
f or pati ents wi t h col lapsi bl e ai rways has been quest i oned (756).
Endoscopy
The LMA has been used to ai d di agnosti c and therapeuti c f i beropti c
l aryngot racheoscopy and bronchoscopy i n adul ts and chi l dren by di rect i ng the
f iberscope t o the gl ot ti s
(72,728,740,761,762,763,764,765,766,767,768,769,770,771,772,773,774,775,776,7
77,778,779,780, 781,782, 783, 784). The LMA has al so been used to f aci l i tate
bronchoal veolar l avage (765,785,786) and t o pl ace a bronchi al st ent (787).
A larger f i beropt i c bronchoscope may be used wi th t he laryngeal mask compared
wi th t he nose or tracheal tube. The LMA-Fl exi bl e i s not sui tabl e f or f iberopti c
exami nati ons because of the narrow t ube and because the i nternal l y seated wi re
may be damaged (105). Venti lati on can be mai ntai ned by usi ng a connector that
i ncorporates a di aphragm opening for t he bronchoscope (see (4) i n Fi g. 7.2). Thi s
al l ows the PEEP appl icat ion, whi ch may i mprove the bronchoscopi c vi ew of the
upper ai rways (128).
The LMA may be helpf ul whi l e pl aci ng a bronchial bl ocker (788, 789). The bl ocker i s
pl aced i n the trachea pri or t o pl aci ng the l aryngeal mask. A bronchoscope i s placed
t hrough the LMA to assist in pl acing t he bl ocker. Af ter t hi s has been accompl i shed,
an appropri at e tracheal tube i s placed t hrough the LMA i nt o the t rachea, and t he
LMA i s wi t hdrawn. Al t ernatel y, the LMA may be placed fi rst and then the bl ocker
posi t i oned t hrough i t.
Tracheal Tube Exchange
The l aryngeal mask can be used to f aci l i tate t racheal tube exchange (790,791,792).
The LMA i s inserted next to the t racheal tube. A f i berscope wi th a tracheal tube
mounted on the f i beropti c porti on i s inserted i nt o the LMA. The f i beropti c scope i s
i nsert ed int o the t rachea next to the ori gi nal t ube. When pl acement i n the t rachea i s
veri f i ed, the ol d tube is removed and the new one advanced over t he scope i nto the
t rachea.
Transesophageal Echocardiography
The LMA has been used in pati ents undergoi ng t ransesophageal echocardi ography
(793, 794,795,796).
Venti latory Support without Tracheal I ntubati on
The LMA can be used f or short -t erm ai rway mai ntenance (797,798, 799, 800,801),
appli cati on of CPAP or PEEP (128,802, 803,804), or pressure-support venti l ati on
(556, 805,806). The laryngeal mask can be used to ai d t racheal sucti oni ng wi thout
resorti ng to i nt ubati on or t racheost omy (807).
Head and Neck Procedures
The LMA has been used for a vari et y of head and neck procedures, i ncl udi ng
l aryngoscopy and
P. 485

mi crosurgi cal procedures on t he larynx (740,757,807,809), nasal and
pharyngoplasti c surgery (811,812,813,814,815,816), myri ngotomi es (633,635),
adenoi dectomy and tonsi l l ectomy
(31,203,223,224,225,635,740,816,817,818,819,820), and dent al procedures
(66,219,816,821,822,823,824,825,826,827,828,829). The LMA has been used in
conjuncti on wi t h a f i beroptic bronchoscope to assi st i n t hyropl ast y (830).
The LMA-Fl exi bl e is part i cul arl y usef ul for procedures i nvolving t he head and neck
area because the tubi ng can be moved about to f aci l i t ate t he surgery, and the wi re
rei nforcement makes the t ube more resistant to ki nking and compressi on than t he
LMA-Classi c. Care must be taken not to di spl ace t he LMA or al l ow i t t o rotat e when
movi ng the ai rway t ube.
The LMA cuff acts to prevent aspi rati on of bl ood, teet h, and secret ions f rom above
t he mask (114,224,225,811,831, 832,833, 834). Furt her protect ion may be obt ai ned
by i nsert i ng an oropharyngeal pack or by posi ti oni ng a sucti on catheter i n the
groove between the mask and the LMA tube (835).
The LMA has been used for thyroi d surgery. The cuf f di spl aces the gland ant eri orl y,
f aci li t ati ng surgi cal access (30,740). Because damage t o the recurrent l aryngeal
nerve i s a compl icati on of thyroi d surgery, i t may be desi rabl e to st imul at e that
nerve duri ng and af t er surgery and observe the moti on of t he vocal cords by usi ng
a fi berscope through the LMA
(23,728,767,768,769,770,771,772,773,774,775,776,777,778,779,780,781,782,783,7
84,785,786,787, 788,789, 790, 791,792, 793, 794,795,796,797, 798,799, 800, 801,802, 80
3, 804,805,806, 807, 808,809,810,811,812,813, 814,815, 816, 817,818,819,820,821,822
, 823,824,825,826,827,828,829,830,831,832, 833,834,835,836,837,838,839,840,841)
. An LMA can also be used to cont rol the t ension and posi ti on of the pharyngeal
wal l t o facil i tat e surgi cal condi t ions (842). Tracheal deviati on and narrowi ng shoul d
be consi dered relati ve contrai ndi cati ons to using the LMA i n t hyroi d surgery.
Ear procedures are wel l sui ted to t he LMA (740,843,844). At the end of the surgical
procedure, i t is i mportant t hat t he pati ent does not cough or strai n. These probl ems
are less li kel y wi th t he l aryngeal mask. A perceived drawback to usi ng the laryngeal
mask i n ear cases i s that of ten the anesthesia provi der is l ocated at the f oot of the
pati ent . Some cl i nicians feel uncomf ortabl e wi th t hi s posi ti on when an LMA i s in
pl ace.
The LMA has been used for standard (650, 655,682,728,845, 846) and percut aneous
di l atati onal tracheost omy
(667, 847,848,849, 850, 851,852, 853, 854,855, 856,857,858,859) (Chapter 21) and f or
i nsert i ng a needl e i nto the t rachea f or j et vent i l at ion (689). Using t he LMA
el i mi nates the need to share t he trachea wi t h the surgeon and avoi ds the possibi l i t y
of cuf f puncture, tube t ransecti on, or acci dent al extubati on. It also all ows the
t rachea to be visual i zed through a f i berscope during the procedure.
The LMA may be used f or carot id endarterectomy (860,861,862,863). Ai rway
management wi t h the LMA i s associ ated wi t h decreased hemodynamic and stress
responses. The surgeon shoul d be warned that neck anatomy may be al tered and
t hat excessi ve neck pressure might di spl ace t he cuf f (863).
Cuf f i nf l at i on and def l ati on has been f ound to decrease and increase bl ood f l ow
t hrough the caroti d artery (864). The cl i nical si gnif icance of this f i nding i s not cl ear,
but cuf f i nf l at ion vol ume and pressure shoul d be kept as low as practi cal .
Pl acement i s somet i mes di ff icul t in pati ents wi t h l arge tonsi l s (50,865). The LMA
t ube may become compressed bet ween t he l ower t eet h and t he Boyl e Davi s gag
bl ade (114, 223,224, 866, 867).
Pediatric Patients
The LMA can be used i n chi ldren, incl udi ng smal l i nf ants
(50,63,276,436,442,454,588,705,783,868,869,870,871,872,873, 874, 875,876, 877, 87
8, 879,880,881, 882). I t may be part icularl y hel pf ul wi th chi l dren in whom unusual
anatomy makes t racheal i ntubati on di ff i cul t (108, 884,885,886, 887). The LMA has
been used i n Treacher Col l i ns, Dandy-Wal ker, Pi erre-Robi n, Gol denhar, Freeman-
Shel don, Beckwi th-Wi edemann, and Sti l l ' s syndromes; congeni tal epul is; and
mucopol ysacchari doses
(98,103,143,479,649,679,681,682,685,701,703,704,705,706,846,884,887,888,889,8
90,891). However, i t may not be usef ul in some pati ents wi th Hunter' s syndrome
(892).
The l aryngeal mask ai rway provi des a usef ul al ternati ve t o the t racheal tube when i t
i s necessary to administer anest hesia to chi l dren wi t h an upper respi ratory i nf ect i on
(893). I n chi ldren wi th bronchopul monary dyspl asia, the LMA can maintai n a
sati sf actory ai rway wi th f ewer adverse respi ratory ef fects t han a tracheal t ube
(894, 895,896). Chil dren wi th subgl ott i c stenosi s may have respi ratory probl ems i f
t his area i s i rri t ated by a t racheal tube. The l aryngeal mask has been used f or
chil dren wi t h this probl em who are undergoi ng surgery t hat i s not rel at ed to the
ai rway (897,898). The l aryngeal mask has been used for hi gh-f requency osci l l at ion
f or a premature i nfant (899).
The LMA has been used for chi l dren who have anesthesi a for radi otherapy and MRI
exami nati ons and f or those who requi re mul t i pl e anesthetics over a short peri od of
t i me (900,901,902,903,904,905). The LMA has been successf ul l y used f or pedi atric
pati ents who have ext racorporeal shock wave l i thotri psy (906). Al though di ff i cul t to
i nsert , the LMA-Fl exi bl e has been used successf ul ly f or pedi atri c dent al surgery
(907, 908). The LMA has been used for pediat ri c cardi ac catheri zat i on (759).
Some studi es show f ewer hypoxi c epi sodes and i mproved surgi cal condi ti ons i n
chil dren who are vent il ated wi th t he LMA as compared wi th a f ace mask (633).
Ot her st udi es have found that there were more compl i cat i ons such as breath
hol di ng, coughi ng, l aryngospasm, secret i ons, obst ruct ion, and oxygen desat urati on
wi th t he LMA when compared wi t h the f ace mask and oral ai rway (909). Some
studi es f ound a t endency f or t he LMA posi ti on to deteri orat e af t er i ni ti al sati sf actory
pl acement i n i nfants (63, 77).
P. 486


Because the epi gl ot ti s in chi l dren i s rel ativel y l arge and f loppy, the l ikel ihood of i ts
bei ng wi thi n the mask i s greater than in adul ts (50,75,79, 910). Thi s may make bl i nd
i ntubat ion or intubat ion over a bougi e or gui de wi re passed through the LMA
di ff i cul t (64).
Smal l er chi l dren are more li kel y to have ai rway obst ructi on, greater i nspi ratory
l eak, and more compl icat ions and requi re hi gher venti l atory pressures t han ol der
chil dren (877,882). The i nci dence of t rauma may be hi gher t han expected (911).
Professi onal Si ngers
The l aryngeal mask may be especi all y useful for prof essi onal si ngers and speakers
i n whom the l aryngeal compl i cati ons of i ntubati on would be most serious (912,913).
The LMA causes l ess change in vocal f uncti on than tracheal i nt ubati on (914).
Remote Anesthesia
Si tuati ons i n whi ch the anesthesi a provider must be away f rom the pat ient,
i ncl udi ng di agnost ic i magi ng and radi otherapy procedures, can of ten be managed
by using a l aryngeal mask (208,229, 900,903,905,915, 916). These procedures are
usual l y associated wi th mi ni mal or no pai n but requi re the pat i ent t o remai n sti l l f or
a period of ti me. If t he pat ient must be pl aced i n an awkward posi t i on and t he area
of i nt erest i s not near t he LMA, t he LMA-Fl exi bl e may be the best choi ce.
MRI poses some speci al problems (Chapter 30). Because some of the i nf l ati on
valves cont ai n metal l i c materi al , i t may be necessary to remove the valve and knot
t he pi l ot tube (917). I f a nonferrous valve i s not avai lable, the val ve can be
posi t i oned away f rom t he area of i nt erest (23). If the LMA-Fl exi bl e, LMA-Fastrach,
or LMA-ProSeal is used, the metal coi l produces a l arge bl ack hole i n the i mage i n
t he area surroundi ng the ai rway as wel l as distorti on of the i mage i n t he area
surrounding the ai rway (229). An LMA may not be sui t abl e if magnet i c resonance
spect roscopy i s perf ormed, because t he resonance of some si l i cone-cont ai ni ng
materi al s compromi ses i nterpretat i on of t he scans (918). The LMA-Uni que can be
used i n thi s ci rcumstance.
Supplementing Regi onal Block
I n cases where surgery outl asts a regional block or onl y a parti al bl ock is present ,
suppl ementat ion wi t h l i ght general anesthesi a may be desi rabl e. In addi ti on, many
pati ents become rest l ess and cannot tolerate prolonged surgery under regi onal
anesthesi a. The LMA can be used i n these si tuat ions, as i t requi res a li ghter l evel
of anest hesi a than would be requi red wi t h a tracheal t ube (626,919).
Resuscitation
Successful use of the LMA-Cl assic and LMA-Fast rach duri ng cardi ac arrest has
been report ed (553, 920, 921,922, 923, 924,925, 926). The presence of an LMA does
not i nterfere wi th palpati on of t he carot id pul se (927). Since the LMA can be
i nsert ed f rom the f ront, side, or head of t he pati ent , i t i s usef ul in entrapment
si tuat ions. The head can be maintai ned i n the neut ral posi t ion i f cervi cal trauma i s
suspected. Bet ter venti lati on can be achi eved than wi th a f ace mask (928,929, 930).
The LMA has been used for neonatal resusci t at ion i n i nfants as smal l as 1.0 kg and
i n neonates wi t h abnormal ai rways
(501, 682,931,932, 933, 934,935, 936, 937,938, 939). Di sadvantages i nclude the
i nabi l i ty to remove meconi um or to admi nister high pressures (940). Thi s may make
i t unsui t able f or resusci t ati on of premat ure newborns or ones who requi re hi gh
ai rway pressures (936).
Nonanesthesi a personnel can l earn the LMA i nsert i on t echni que easi l y
(846, 941,942,943). The LMA-Fastrach may be superi or to the LMA-Cl assi c for
i nexperi enced personnel (944). I nt ubat i on wi t h this devi ce can be l earned more
easi l y and rapi dl y than tracheal i ntubat i on usi ng laryngoscopy (945,946). It i s
pref erred by personnel who use an over-the-pocket f ace mask or mout h-t o-mouth
contact f or exhal ed ai r vent i l ati on (947,948).
The LMA shoul d not be consi dered a subst i tut e f or a t racheal tube if someone
present has t he abi l i t y to pl ace a t racheal tube.
The LMA cannot off er f ul l protect ion f rom aspi rati on. Regurgi tat i on i s l ess wi th t he
LMA than wi t h a bag-val ve-mask devi ce (949). The LMA does off er protect i on f rom
aspi rat ion f rom above the l arynx, i ncl udi ng bl ood f rom t rauma (805).
The LMA shoul d not be used i f the pati ent is not profoundl y unconscious or resi sts
i nsert i on. It may not be possi bl e to adequatel y venti l ate pati ents who requi re
posi t i ve-pressure venti l ati on and who have poorl y compl i ant l ungs wi t h pul monary
edema, aspi rati on, or obst ructi ve pulmonary disease.
Out-of-hospital Use
The LMA has been used in out-of -hospi tal si tuati ons, i ncl udi ng ai r transfers
(950, 951,952,953). It has proven usef ul i n pat ients wi th cervical spi ne i nj ury and in
t hose t rapped i n posi t ions that do not l end t hemsel ves to t racheal i ntubati on
(954, 955). I ts ease of i nsert ion may make i t usef ul i n the scenari o of a t oxi c mass
casual t y event (956).
Paramedics and respi ratory therapists can acqui re ski l l s more rapi dl y and have a
hi gher rat e of successf ul placement wi t h the LMA t han wi th a tracheal tube
(846, 957,958,959, 960, 961,962). However, whi l e LMA pl acement by paramedics is
usual l y successf ul , bl ind t racheal i ntubati on t hrough i t i s not associ ated wi th a hi gh
success rate (963).
Obstetrics
Because the ri sk of aspi rati on of gast ri c contents i s hi gh in t he obstet ri cal pat i ent ,
t he use of an LMA i s usual l y not recommended (964). However, i t has been
P. 487

used i n heal t hy part uri ents f or el ect i ve Cesarean sect ion (671,965). If i ntubati on
cannot be performed, the LMA may be l i f esavi ng
(652, 657,661,669, 670, 966,967, 968, 969,970, 971,972). For this reason, and because
t he i nci dence of fai l ed i ntubat ion i n the obstet ri c popul ati on is higher t han in t he
general popul ati on, laryngeal masks shoul d be kept in every obstet ri cal operati ng
room. The LMA-ProSeal is probabl y a bett er choi ce than the LMA-Cl assic f or t hi s
use.
I n t he obstetric pati ent who can be venti l ated by usi ng a face mask whi l e cri coid
pressure i s conti nuousl y appl i ed, pl acing the LMA may have l i tt l e benef i t and mi ght
i nduce vomi ti ng and aspi rat i on. Si nce cri coi d pressure of ten i nhi bi ts LMA
pl acement , cri coi d pressure may need to be momentari l y rel eased to al l ow the LMA
t o be successful l y i nsert ed. The l aryngeal mask may not al ways be ef f ect ive i n the
obstetric pati ent (973).
The l aryngeal mask has been i nsert ed by using t opi cal anesthesi a and has been
used to f aci l i tate t racheal intubat ion i n a parturi ent (974).
Laser Surgery
The LMA has been used for l aser surgery on t he f ace (975,976), pharynx (812,977)
and subgl ot ti c areas (72,742,978,979). The manuf acturer does not recommend t hat
t hese devi ces be used wi t h l asers. Al though LMAs, wi th t he except ion of the LMA-
Uni que and the LMA-Fastrach, are more resi stant t o perf orat ion by l asers t han
pol yvinyl chl ori de or wi re-rei nf orced tracheal t ubes, t hey can be igni ted at cli ni cal l y
used power densi t ies (980,981,982). Operati ng room f i res are discussed in Chapt er
32. The cuf f and t he bl ack markers on the tube are t he most vul nerabl e areas
(204). The LMA t ube shaf t shoul d be wrapped i n a laser-resi stant materi al and the
cuff protected wi th wet gauze and fi l led wi t h sal ine (596,977,982,983). A gauze bi te
bl ock shoul d not be used (976). I t i s i mportant that resi dual fl ui d i n the cuf f be
removed and dri ed wi th t he i nfl ati on val ve open (596). An i mportant advantage of
using t he LMA f or laser t reatment vi a the f lexi bl e endoscope i n pati ents wi t h
t racheal tumors i s the gas f l ow- resistance characteri sti cs t hrough t he LMA
compared wi t h a t racheal tube (105).
An i ntubat i ng l aryngeal mask can be used to f aci l i tate l aser-resistant t racheal tube
pl acement (984).
Laparoscopy
Use of the LMA f or l aparoscopi c procedures i s controversi al , because i t does not
of fer def ini t ive protecti on f rom pul monary aspi rati on of gastric contents
(986, 987,988,989, 990). St udi es suggest that t he LMA i s safe f or gynecol ogic
l aparoscopy (662,990,991,992,993,994,995,996). I t has also been used
successf ul l y f or l aparoscopi c chol ecystectomy (31, 423, 432,448, 997, 998,999), but a
case of aspi rat ion has been report ed (1000). The LMA-ProSeal is recommended f or
t hese procedures (432,1001,1002).
Lower Abdomi nal Surgery
A number of studi es i ndi cate that the LMA is safe f or l ower abdomi nal procedures
such as hysterectomy and ret ropubi c prost at ect omy. Adequate anesthesi a depth to
prevent coughi ng duri ng peri t oneal st i mul ati on needs to be mai ntai ned (31).
Neurosurgery
The LMA has been used for pat i ents undergoi ng ventricul operi t oneal shunts (1003)
and i nt racrani al surgery (1004,1005,1006, 1007,1008,1009, 1010). Hemodynamic
stabi l i ty associ ated wi t h the LMA may be especial l y benef i ci al i n pat ients
undergoi ng procedures where hypertensi on must be avoi ded, such as repai r of an
i ntracrani al aneurysm, and i n pat ients wi th i ncreased i ntracrani al pressure. The
LMA can be used to provide a smoother emergence f rom anesthesi a af ter
i ntracrani al or spi nal surgery (1011).
Cervi cal spi ne di sease is of ten associ ated wi t h head and neck i mmobi li t y, whi ch
can be associ ated wi t h dif f i cul t t racheal i ntubati on. Use of the LMA-Fastrach may
enabl e t racheal i ntubati on wi t hout the need to manipul ate t he head and neck
(246, 261,1012).
Unstable Cervical Spine
The opti mal ai rway management for t he pati ent wi t h an unstabl e cervi cal spi ne i s
controversi al . Whi le the LMA requi res l ess cervical manipulati on duri ng intubati on
t han di rect l aryngoscopy, i t produces f l exi on and posteri or cervi cal spi ne
di spl acement despi te manual st abi l i zat i on (260,359,1013,1014). Thi s mot ion i s i n
t he opposi te di recti on of laryngoscopy. Some invest i gators f eel that the LMA shoul d
not be used f or t he pati ent wi th an unstabl e cervi cal spi ne unl ess i ntubat i on by
standard techni ques i s unsuccessf ul (359,1015).
Extubati on
The LMA can be substi tuted f or t he tracheal t ube whi l e the pati ent is st i ll in a deep
pl ane of anesthesi a or bef ore antagoni sm of neuromuscular bl ockade to f aci l i tat e a
smoother emergence f rom anesthesi a
(781, 798,1011,1016,1017, 1018,1019,1020,1021, 1022, 1023,1024,1025,1026, 1027).
The LMA i s pl aced behi nd the t racheal tube, and the cuff i s i nf l ated. Correct
l aryngeal mask posi ti on can be conf i rmed by using a f iberscope or a capnograph.
The t racheal tube cuf f i s then defl ated, and the t racheal t ube i s removed as soon as
t he pat ient resumes spont aneous breathi ng. An exchange catheter or bougie may
be used to f aci li t ate rei nsert i on of the t racheal tube, i f t hi s i s needed (984).
The LMA may be used to mai ntai n an ai rway when acci dental ext ubati on occurs and
rei ntubat ion would be dif f i cul t (1028).
P. 488


The LMA can be used t o aid di agnosi s of l aryngeal edema bef ore extubat ion by
using a f iberscope (1029).
Access to the Upper Gastroi ntesti nal Tract
The LMA can be used t o di rect a gast roscope or nasogastric tube i nto t he
esophagus (1030, 1031). The LMA-ProSeal i s speci all y desi gned to f aci l i tate the
passi ng of an enteral tube.
Extracorporeal Shock Wave Lithotripsy
Ext racorporeal shock wave l i thot ri psy requi res very l i mi ted diaphragmatic mot i on to
l ocal i ze the ureteral stone. The LMA i n combi nati on wi t h hi gh-f requency j et
venti l ati on can reduce mot ion and make this procedure more ef f ici ent (1032).
Complications
Aspiration of Gastri c Contents
The LMA does not f orm a wat erti ght seal around the l arynx and cannot be rel i ed on
t o protect the t racheobronchi al tree f rom the contents of the gast roint esti nal tract
as rel i ably as can a t racheal tube
(686, 1000,1033,1034,1035, 1036,1037,1038, 1039,1040,1041,1042,1043,1044,1045,
1046, 1047,1048,1049,1050). The overal l i ncidence of gast ri c content aspi rat ion i s
l ow and has been report ed as 2.3 per 10,000 to 10.2 per 10,000 i n adul ts (1033).
Many report ed cases of aspi rat ion wi t h the LMA are associ at ed wi t h pat ients who
are considered i nappropriat e for the LMA-Cl assic (gast rointesti nal pat hol ogy,
obesi ty, ai rway problems, depressed l evel s of consci ousness, Trendel enburg or
l i t hotomy posi t i on, hi st ory of ref l ux or emergency surgery, and t rauma), but cases
of aspi rati on in f ast ed pati ents wi t h no predi sposing factors duri ng el ect ive
procedures have been reported (1033). Aspi rat i on is l ess l i kel y wi t h the LMA-
ProSeal , al though aspi rati on may resul t i f the tube i s not correctl y pl aced (414).
Gastroesophageal ref lux may be a precursor t o aspi rati ng gastric contents. No
correlati on has been found bet ween pressure and vol ume i nsi de t he cuf f and
vari ati ons in esophageal pH (1050). The i nci dence of ref l ux i s the same wi t h
spontaneous and posi t i ve-pressure venti l ati on (19,1036,1051). The risk of refl ux i s
i ncreased if t he LMA remains in pl ace unti l t he pat ient can open the mout h on
command as opposed to removal on t he f i rst si gn of rej ecti on (581, 582, 1052).
Regurgi tat ion usual l y occurs wi thout warni ng. I t i s of ten associ ated wi th l i ght
general anesthesi a. The fi rst indi cat ion i s of ten the appearance of gastric
secreti ons i n the tube. Fortunately, most of the report ed cases have had favorabl e
outcomes because the regurgi t ated mat eri al was not aspi rated or t he aspi rat ion was
rel ativel y mi l d.
St udi es suggest an inci dence of aspi rat ion of 1 i n 5000 t o 12, 000 pati ents wi th t he
LMA-Classi c (662,1046,1053). The i nci dence appears t o be far lower wi th t he LMA-
ProSeal (409).
A reducti on in l ower esophageal sphi ncter tone may occur when a l aryngeal mask i s
used (1054, 1055). However, t he upper esophageal sphi ncter remai ns competent
and can prevent regurgi tat i on i n the absence of neuromuscular bl ock (1056). Duri ng
general anesthesi a wi th the LMA, t he pharyngeal ref lex i s bl ocked or mi ni mal and
does not aff ect esophageal mot il i t y (1057). A study i n cadavers f ound that correctl y
pl aced LMAs attenuat ed li qui d f l ow bet ween t he esophagus and pharynx (1058).
There i s si gni fi cant impai rment of the cough ref lex f ol l owi ng LMA use (1059).
Vomi t i ng i s rare whi l e the l aryngeal mask i s i n use. An i nci dence of 0.4% was
reported i n a large retrospect i ve st udy (1060). There was no aspi rati on in thi s
study.
I n t he event of a f ai l ed int ubati on i n a pati ent for whom there i s a si gnif i cant ri sk of
aspi rat ion and in whom venti l at ion can be mai nt ai ned wi t h a face mask whi l e cri coi d
pressure i s appl i ed, i t may be safer to conti nue wi t h t he f ace mask and cricoi d
pressure rather t han t ry t o i nsert t he LMA (1061). Appl ying cri coi d pressure may
make posi ti oni ng the LMA more di f f i cul t and may decrease t he success of
venti l ati on (25,32, 34,35,38, 1062). It i s probabl y a good i dea t o momentari l y rel ax
cricoi d pressure whi l e the LMA is i nsert ed. The LMA does not decrease cri coi d
pressure ef f ectiveness, so cri coi d pressure shoul d be reappl i ed and mai ntai ned
af ter the LMA i s i nserted unl ess i t interf eres wi t h vent i l at i on (1063, 1064).
The i nci dence of aspi rati on can be reduced by l imi ti ng t he el ect ive use of the LMA
t o f asti ng pat ients who are not at i ncreased ri sk f or gastroesophageal ref l ux.
Gastric di st ent i on can be mi ni mi zed by usi ng the correct si ze mask, avoidi ng under-
or overinf l at ing t he cuf f , caref ul posi t i oni ng and f ixat ion, mai ntaining adequate
anesthet ic depth and rel axati on throughout surgery, and l ow i nf lati on pressures.
The use of l ow ti dal vol umes and l ow i nspi ratory f l ow rates wi l l hel p to keep peak
ai rway pressure low. The mean pressure at whi ch gastric i nsuff l ati on occurs is 28
cm H
2
O wi th a range of 19 t o 41 cm H
2
O when usi ng size 4 and 5 LMAs (1065).
Epi gastri c auscul tat ion should be perf ormed t o ensure t hat gast ri c i nsuf f l at ion i s
not occurri ng. A nasogastric t ube may be used but may not al ways be hel pful
(895, 1096). The use of pressure-cont rol l ed rather t han vol ume-control led
venti l ati on (Chapter 12) may resul t i n lower i nf l at ion pressures (1067).
During spontaneous respi rat ion, i t is i mportant to mai ntai n an adequate l evel of
anesthesi a because gast ri c di stenti on resul ti ng f rom recurrent swal l owi ng can occur
when anest hesi a i s too l i ght (1068,1069). Degl uti on f requency may be i ncreased by
t he LMA (1070). Even i n the presence of deep anest hesia and i n the absence of
ri sk f act ors, aspi rat i on can occur.
I f gastric contents are seen in t he laryngeal mask, the pati ent should be pl aced i n
t he 30 head-down posi t i on, the LMA lef t i n si tu, anesthesi a deepened, and
P. 489

t he breathi ng system di sconnected temporari l y to al l ow drai nage. The l at eral
posi t i on has no apparent advantage, as regurgi tated f luid i s prevent ed f rom
escapi ng vi a the pharynx. Oxygen should be suppl i ed. Forceful venti lati on at tempts
shoul d be avoi ded and smal l t idal vol umes del i vered. Sucti oni ng shoul d be
perf ormed via the LMA, pref erabl y by usi ng a fi berscope. The LMA shoul d be
repl aced wi t h a t racheal tube if aspi rati on has occurred.
I f the LMA-ProSeal is being used and unexpect ed regurgi tat i on occurs, fl ui d wi l l
emerge f rom the drai n tube. I t has been shown i n cadavers t hat f l uids exi t vi a the
drai n t ube wi t hout l aryngeal cont ami nat ion when the mask has been correctl y
pl aced. In t hi s si tuati on, i t i s not necessary to remove t he LMA-ProSeal i f the
oxygen saturat i on remai ns at accept abl e level s (377).
Gastri c Distention
Gastric di st ent i on, whi ch has been i mpl icated as a f actor i n aspi rati on, can occur
wi th posi tive-pressure venti l ati on
(15,50,109,549,551,552,873,874,1071,1072, 1073). The i ncidence of gast ri c
di stent i on increases wi th i ncreasing ai rway pressure and t i dal vol ume but i s
unl i kel y to occur at ai rway pressures of l ess t han 20 cm H
2
O (30 cm H
2
O f or t he
LMA-ProSeal ) i f the LMA i s properl y posi ti oned. The use of pressure-l i mi t ed rather
t han vol ume-l imi ted vent i l at i on may hel p to avoid gast ri c di latat i on (1074). The ri sk
of gast ri c insuf f l at ion is i ncreased if the LMA i s not properl y posi ti oned (1075).
Epi gastri c auscul tat ion i s a fai rl y rel iabl e techni que for detect i ng gast ri c i nf l at i on
(1076).
Forei gn Body Aspiration
A f orei gn body may become entrapped in t he LMA tube
(1077,1078,1079,1080, 1081,1082,1083). Such an object may be subsequent l y
aspi rated or cause ai rway obst ructi on. Chewi ng gum has been f ound on the upper
surf ace of an LMA upon removal (1084).
Airway Obstruction
Report ed causes of compl et e or parti al ai rway obstructi on whi le using a l aryngeal
mask i nclude mal posi ti oni ng, di stal cuff backf ol di ng, epiglott ic backf ol di ng, f or ward
di spl acement of the postcricoid area, aryepi gl ot ti c fol d i nfoldi ng, arytenoi d carti l age
di sl ocati on, l aryngeal openi ng obstruct i on by the cuf f , t ube kinking, i ncreased cuf f
volume, cuf f herni at ion, l ubricant appl ied t o the mask aperture, the LMA-ProSeal
bowl foldi ng i nward, a f aul ty LMA, f orei gn body presence, a supraglot t ic tumor or
l i ngual t onsi l l ar hypertrophy, appl i cat i on of cri coi d pressure, f i ri ng f rom a vagal
nerve si mul at or, and l aryngospasm
(30,33,63, 66, 78,208,462,514,536,560,663,904,1063,1069,1085, 1086,1087,1088,108
9, 1090,1091,1092,1093, 1094,1095,1096,1097,1098,1099,1100, 1101,1102,1103,110
4, 1105,1106,1107).
The report ed incidence of laryngospasm is 1% t o 3% and may occur anyt i me duri ng
t he peri operati ve peri od (63,1108,1109,1110, 1111,1112). Laryngospasm usual l y
resul ts f rom i nadequate anesthetic depth or l ubri cant on the ant eri or surf ace of the
mask. St ri dor has been report ed for as long as 2 days f ol lowi ng uneventf ul use of
an LMA (1113, 1114).
Bi ti ng t he tube can cause obstructi on and damage the LMA (562). Thi s can be
avoided by i nserti ng a bi te bl ock or gauze rol l and l eavi ng i t i n pl ace unti l the LMA
i s removed. However, a bi te block may be def ormed (1115). The LMA-ProSeal has
a bui l t-i n bi te bl ock bet ween the two t ubes, whi ch may prevent this problem. Mouth
gags used f or surgery may cause obstructi on of the LMA tube (223,820).
Ai rway obst ructi on may be caused by the LMA rotati ng i n such a way t hat the cuf f
occl udes t he larynx (230,1116, 1117). Rotati on can be detected by checki ng for the
bl ack l i ne, which shoul d face the upper l i p.
Appl ying cri coi d pressure or downward pressure on the mandi bl e by the surgeon
may cause ai rway obst ructi on wi t h t he l aryngeal mask i n pl ace (825,1062).
Changi ng f rom si ngl e-handed to bi manual cri coid pressure appl icati on may resolve
t he probl em (663).
I f ai rway obst ructi on devel ops, rapid f iberopti c endoscopy may hel p to di f ferent i ate
t he various causes and gui de appropriate management (1086, 1118,1119,1120).
Maneuvers that may help t o rel ieve obstructi on include minor j aw or LMA
adj ustments, mandi bul ar prot rusi on, head extension, and unki nki ng of the LMA t ube
(63,1102). I n most cases, the LMA shoul d be removed and rei nsert ed or a di ff erent
si ze LMA used.
Trauma
A number or t raumati c injuri es have been reported. These incl ude i njuri es t o the
epi gl ot ti s, posteri or pharyngeal wal l , uvula, sof t palate, t ongue and t onsi l s
(865, 1045,1110,1121,1122, 1123,1124,1125, 1126,1127,1128); a hematoma above
t he vocal cords i n a pati ent wi t h a bl eedi ng di at hesi s (1129); esophageal
perf orati on af ter bl i nd i nt ubat i on through the i nt ubat i ng LMA i n a pat ient wi th a hi gh
esophageal pouch (319); aryt enoi d and temporomandi bul ar j oi nt di sl ocati on
(1094,1130,1131); t ongue cyanosi s (1132, 1133); and complet e di srupt ion of a clef t
sof t palate repai r (1134).
The i nci dence of sore t hroat f ol lowi ng use of t he LMA has been report ed to be
bet ween 0% and 70%
(73,199,234,248,475,506,519,630,634,716,946,965,993,1069,1110,1111,1135,1136,
1137, 1138,1139,1140,1141, 1142,1143,1144,1145, 1146,1147,1148,1149,1150). The
i nci dence is l ess than wi th a t racheal tube but more than when a face mask i s used
(1151,1152). The use of an i nserti on ai d and cuff defl at or may l ower t he i nci dence
(1138,1153). Inserti ng the LMA f ul ly or parti al ly i nf l ated wi l l reduce the inci dence
(89). Use of l arger LMAs i s associ at ed wi th a hi gher i nci dence of sore throat
(5,1154,1155). The inci dence of sore
P. 490

t hroat i ncreases wi t h use and l eaving t he LMA i n si t u af ter i nt ubati on
(346, 348,358,1156).
St udi es di ff er on t he ef fect of i nt racuf f pressure on the inci dence of sore throat
(1143,1145,1148). Some studi es have shown that l oweri ng cuf f pressure may
decrease the incidence of sore throat and dysphagi a, especi al l y i n women
(1069,1144,1151,1157). Other st udi es have f ound no correl ati on bet ween sore
t hroat and cuff pressure (234). The pressure on the mucosa beneath the full y
i nf l ated cuff may be greater than capi ll ary pressure (535,537,538), rai si ng concerns
about i schemic damage t o the mucosa or ref lex rel axati on of the l ower esophageal
sphinct er (1158,1159). Provided the i nt racuf f pressure i s kept at 60 cm H
2
O,
mucosal pressures wi l l be less than those consi dered saf e f or prol onged tracheal
i ntubat ion (1160). There is evidence t hat t he pharynx may adapt to t he LMA cuf f
(538).
Bl ood on t he laryngeal mask occurs l ess of ten i f the l aryngeal mask is removed
defl ated than i f i t i s removed wi th the cuf f parti al l y i nf l ated.
Dysphagia i s seen more f requent l y af ter LMA use than when a t racheal tube or a
f ace mask i s used (1143, 1151). The i ncidence of dysphagi a may or may not be
rel ated t o cuf f pressure (234,1144,1151).
Posteri or Spi nal Li gament Rupture
A case of posteri or spi nal l i gament rupt ure wi th quadriplegi a f ol l owi ng l aryngeal
mask i nsert i on in a pati ent wi th an unstabl e cervi cal spi ne has been report ed
(1161).
Dislodgment
Acci dent al di sl odgment can occur (728,735,736,825,874). A correctl y pl aced LMA
may be f orced upward out of t he hypopharynx i f cri copharyngeal muscl e tone i s
permi tt ed to i ncrease or if the cuff becomes overi nf l ated. The LMA may get caught
i n the groove of a tongue bl ade, whi ch can l ead to premature removal (635). Thi s
can be avoi ded by coat ing t he groove wi t h l ubri cant jel l y.
I f the LMA has come out onl y a short di stance, i t can of ten be pushed back i nt o
pl ace (30). Persi stent di f fi cul t y in keepi ng the LMA i n posi t ion may be sol ved by
using a di f ferent si ze mask, reduci ng the cuf f vol ume, el evati ng t he mandible, or
using a di f ferent head posi t i on.
Damage to the Device
The LMA may break apart (520,1069, 1162,1163,1164, 1165,1166,1167) (Fi g. 17. 19).
Thi s i s usuall y occurs when the LMA i s beyond i ts useful l i fe span. The tube can be
t ransect ed by t he pati ent bi t ing i t (562,1168,1169, 1170,1171,1172). The cuff or
pi l ot tube may be torn on a tooth or denture, damaged by surgery or by inserti on of
an i nt ravenous cathet er or nerve block needle
(396, 469,470,1173,1174,1175,1176, 1177,1178,1179,1180, 1181,1182). The devi ce
may be damaged duri ng removal (1183,1184).

View Figure

Figure 17.19 This LMA came apart during autoclaving. It
had been used more than the recommended number of
times.

To prevent the problem of pi l ot bal loon tubing being caught i n the snare used for
t onsi l lectomy, t he tubing shoul d be caref ul ly t aped (1185,1186).
The wi ri ng i n a f l exi bl e LMA may become def ecti ve (226,227). This may resul t i n
ai rway obst ruction, or t he wi res coul d break off and migrate into the
t racheobronchi al t ree.
The 15-mm connect or may l oosen af ter a f ew aut ocl ave cycl es (1187). A case has
been report ed where the connector was removed and reversed (1188).
I f the LMA l eaks in si tu, of ten t he pat i ent can be venti lated by usi ng a f ace mask
over i t (19,1189).
Fail ure of the Cuff to I nflate or Defl ate
I n one report ed case, t he pi l ot tube became stuck bet ween t he pati ent 's t eeth, so
t he cuf f coul d not be i nf l at ed (1191). I n anot her case, the pi l ot t ube became looped
around the mask aperture bars (1191). In yet another case, the pi l ot tube became
wedged bet ween t wo teeth, and t he cuf f coul d not be def l ated (1192).
Nerve I njury
Pal si es of t he hypogl ossal (1193,1194,1195, 1196, 1197,1198), recurrent l aryngeal
(484, 1130,1199,1200,1201, 1202,1203,1204, 1205,1206,1207,1208,1209,1210,1211),
and l i ngual (1212,1213,1214, 1215,1216,1217) nerves have been report ed af ter
using an LMA. Local anest hesi a appl i ed to the LMA can mi mic nerve i nj ury and
cause vocal cord paral ysis (1201).
Bronchospasm
Bronchospasm associ ated wi t h the l aryngeal mask has been report ed
(530, 1109,1218). A bronchodi l ator aerosol can be admi ni stered t hrough t he LMA
(530).
Pulmonary Edema
Pul monary edema has been report ed af ter a l aryngeal mask was i nserted
(1219,1220,1221,1222). In each case, there was
P. 491

preceding ai rway obstructi on wi t h spontaneous vent i l ati on. The LMA-ProSeal drai n
t ube may l imi t negati ve i nt rat horacic pressure and protect against this compl icati on
(420).
Other
Transi ent sal ivary glands and tongue swel l ing and si aladenopat hy have been
descri bed in associ at i on wi t h the l aryngeal mask ai rway
(1223,1224,1225,1226, 1227,1228,1229). Hiccups can occur (1230). Uni lateral
supraglott ic and vocal cord edema have been report ed af ter usi ng an LMA
(1231,1232).
An LMA may di stort the anatomy and di spl ace mobi l e landmarks used to cannul ate
t he i nternal jugul ar vei n or other neck structures (1233,1234,1235, 1236), cause
spuri ous diagnosi s of a cervical mass (1237), or cause the surgeon to damage l ocal
st ructures (1238). Ul t rasound gui dance i s suggested to avoi d probl ems wi t h
cannul at ion of the j ugular vei n.
LMA cuf f i nf lat i on and defl at i on has been f ound to decrease and i ncrease bl ood
f low t hrough the caroti d artery (864). Venous congest i on in t he neck can be caused
by an overi nf l ated cuf f (1239).
The pi l ot t ube of a t racheal tube may become ki nked when i nsert ed through a
l aryngeal mask (1240).
Advantages
Ease of Insertion
An outstanding f eature of the LMA i s that i t rapi dl y provides a clear ai rway i n t he
vast maj ori t y of pati ents and i s f aster and easier to i nsert t han a tracheal tube
(1241). The workl oad associ ated wi t h LMA i nsert i on is l ower t han f or other methods
of ai r way management (1242). The i nsert ion t echni que is simpl e, and even those
wi th l i t t l e or no pri or experi ence are usual l y successful at i nsert ing i t correct ly.
Trai ning for proper i nsert i on i s nei ther l engthy nor el aborate. Peopl e who are not
ski l l ed at i ntubat ion have a hi gh success rate wi t h the l aryngeal mask
(924, 945,961,1243,1244).
Report ed f i rst -t i me i nserti on rates in adul ts vary f rom 76% to 96% i n adul ts
(588, 959,961,1110,1111,1135,1140, 1142,1245,1246,1247). Sl ightl y l ower f i rst -t i me
i nsert i on rates may occur wi th pediatric pati ents
(50,75,77, 588, 633,876, 900, 1109,1112,1248). Studi es show t hat an unobstructed
ai rway can be achieved i n greater than 90% of cases
(50,63,79, 588, 633,900, 1110,1111,1135,1246, 1247,1248,1249,1250, 1251). Wi t h
experience, the success rat e i ncreases and may exceed 99% (109,662,874).
The LMA can be inserted wi th t he pat i ent i n almost any posi ti on where access to
t he mouth i s possi bl e (1252,1253,1254, 1255,1256). Thi s makes i t useful f or
mai ntai ning t he ai rway af ter acci dental extubati on when t he pat ient i s not supi ne
(1256,1257,1258).
The LMA has been used in out-of -hospi tal care when access to the pati ent was so
l i mi ted t hat i t was i mpossi bl e to i nsert a tracheal t ube (954). A cervi cal col l ar or
manual i n-l i ne stabi l i zati on does not appear to i nterf ere wi t h successf ul pl acement
(24,26).
Smooth Awakeni ng
The LMA al l ows a smoother awakeni ng than a t racheal tube wi t h fewer epi sodes of
desaturati on, breath holdi ng, coughi ng, l aryngospasm, and hypertensi on
(50,224,723,1139). Pat i ents wi t h an LMA have bet ter oxygen saturat ions and l ess
coughi ng t han pat i ents who have an oral ai rway i n place during emergence
(1019,1022). Pat ients who have had an LMA requi re l ess anal gesia duri ng recovery
t han those who have been i nt ubated (506).
Low Operating Room Poll uti on
There i s l ess operat ing room pol l uti on wi th an LMA t han wi th a face mask
(550, 1111,1259,1260,1261, 1262,1263,1264, 1265). Duri ng spontaneous vent i lat i on,
t race gas concent rati ons are comparabl e t o those wi th a tracheal t ube (1262).
Usi ng a cl ose (l ocal ) scavengi ng devi ce wi l l l ower the l evel s of trace anest het i c
gases to t hose associ ated wi t h tracheal i ntubati on during posi ti ve venti l ati on.
Avoiding the Complications of I ntubation
Whi le bl ood pressure and heart rat e usual l y i ncrease af ter a l aryngeal mask is
i nsert ed, t hese i ncreases are si mi l ar t o t hose seen af ter i nserti on of an oral ai rway
and are l ess marked and of short er durat i on t han t hose associ ated wi t h t racheal
i ntubat ion or if a Combi tube i s used
(506, 722,723,861, 1139,1266,1267,1268, 1269,1270,1271,1272,1273,1274,1275,127
6, 1277). There i s mi nimal i ncrease i n i nt raocular pressure foll owi ng i nserti on.
The stress and anxi et y associ ated wi t h fai l ure t o int ubate are decreased. The ti me
needed f or i nserti on i s usual l y l ess t han that needed f or t racheal int ubati on
(958, 959,961). Inadvertent bronchi al or esophageal intubat ion cannot occur.
Less anesthesi a is needed to tol erate a l aryngeal mask t han a t racheal tube
(476, 1152,1278). Nei t her l aryngoscopy nor a neuromuscul ar bl ocki ng agent i s
requi red, t hus preventi ng associ ated probl ems such as muscle pai ns and trauma to
t he l i ps, gums, and teeth. Si nce muscle rel axants are not needed, compl i cati ons
associ ated wi th t hem are avoi ded. Thi s i s advantageous f or pat ients wi t h
myastheni a gravi s (1279). For LMAs other than the LMA-Fl exi bl e, t he LMA provi des
l ess resi stance to f l ow than the correspondi ng si ze t racheal tube; paradoxi cal
i nspi ratory movement i s si gni f i cantl y l ess when breathi ng through an LMA than a
t racheal tube (1280).
Emergence and recovery t imes are short er wi t h t he LMA (634,1281,1282).
Emergence is smoother wi th l ess coughi ng, st rai ni ng, breath hol di ng, fewer
P. 492

cardi ovascular changes, and i mproved oxygen saturat ion
(423, 716,722,996, 1139,1241,1283,1284, 1285). There is a l ower i nci dence of
t rauma, sore throat, dysphoni a, and dysphagi a
(234, 506,630,722, 723, 1137,1143,1146).
Si nce t he LMA is not introduced into the l arynx or trachea, l aryngeal or subgl ott ic
edema or trauma shoul d not occur. However, l aryngeal ref l exes may be depressed
(1059). Mucoci l i ary transport vel oci t y is l ess i n pati ents who have a tracheal tube i n
pl ace compared wi th those who have the LMA (1286). Thi s may have i mpl i cati ons
f or reduci ng t he ri sk of retai ned secreti ons, at el ectasi s, and pul monary inf ecti on.
The i nci dence of bacteremia i s low when t he l aryngeal mask i s used (1287, 1288).
The LMA can be used i n pat ients wi t h t racheal abnormal i ti es where a tracheal tube
mi ght cause t rauma (743,1289, 1290,1291). The use of an LMA avoids disturbi ng a
t racheal stent (1292,1293,1294).
Asthmat i cs and other pat ients wi th reactive ai rway disease are at i ncreased ri sk of
bronchospasm duri ng manipul ati ons of thei r ai rway. Because t he LMA i s l ess
i nvasive than a t racheal tube, the ri sk of bronchospasm i s reduced (1295,1296).
However, the LMA may be unsui tabl e for the pati ent wi t h acute ast hma who
requi res high ai rway pressures.
Ease of Use
Because there is no need to support t he jaw or hol d a f ace mask, the cl inici an's
hands are f ree for other tasks. Ai rway deteri orati on f rom user fat i gue i s el i mi nated.
I ntraoperati ve ai rway mani pul at ions, di f f i cul t y i n mai ntaining a patent ai rway, and
hypoxemia are less common wi th t he LMA than wi t h a f ace mask
(225, 633,634,1297).
Avoiding Face Mask Compl icati ons
The LMA avoi ds many of the compl i cati ons associated wi th a f ace mask (Chapter
16) includi ng dermati t is and i nj ury t o the nose, eyes, teet h, and nerves of the face
(975, 1298,1359). The i nci dence of a sore j aw i s l ess than when a f ace mask i s used
(1151). I t provi des protect i on f rom aspi rati on of nasal and oral secreti ons. The
anesthesi a provi der' s hands are f ree, mi ni mi zing fat i gue and potenti al ai rway
deteriorat i on and al l owi ng the provi der to perf orm other t asks. There are f ewer
episodes of oxygen desaturat ion (1111). Gast ri c inf l at ion i s l ess l ikel y to occur.
Protection from Barotrauma
Barot rauma i s a potent i al probl em wi t h tracheal tubes because of t he ti ght seal
i nsi de the trachea. I t is l ess l i kel y to occur wi t h a l aryngeal mask (1300).
Cost-effecti veness
Whi le t he ini ti al price of a reusabl e LMA is high compared wi t h a di sposabl e face
mask or tracheal tube, i t may be a cost -eff ect ive choi ce i f i t is reused enough ti mes
(1301,1302).
Some have report ed 200 to 250 uses (600,1303). The manuf acturer does not
recommend i t being used more than 40 ti mes. I ts l i fe span is prol onged by caref ul
use, st ri ct adherence to cl eaning, checki ng and steri l i zat i on procedures, and
avoiding f orcef ul removal t hrough parti al l y cl enched teeth (19). There may be
savi ngs f rom reduced use of muscl e rel axants, vol at i l e anesthet ics, narcoti cs,
ai rways, and sucti on equipment ; i ncreased pati ent turnover; and reduced
postoperati ve morbi di ty. It can be used wi t h l ow f resh gas f l ows.
Unexpected ai rway management probl ems, especi al l y the i nabi l i t y to i ntubate, of ten
waste consi derabl e operat i ng room t i me at signif i cant expense. The use of an LMA
may short en t he ti me spent establ i shi ng a rel i abl e ai rway. However, the reduced
anesthesi a i nducti on ti me i n most cases i s smal l (1304).
Acci dent al di sposal of reusabl e LMAs can be costl y (1305). Thi s can be mi ni mi zed
wi th i n-service educati on of the st af f . Some f orm of accountabi l i ty may be
desi rabl e.
Disadvantages
Unsuitable Situati ons
Rel at ive cont raindicat ions to use of the LMA i ncl ude si t uat i ons associ at ed wi th an
i ncreased ri sk of aspi rat i on (f ul l st omach, previ ous gast ri c surgery,
gastroesophageal ref l ux, diabeti c gastroparesis, over 14 weeks pregnant , dementi a,
t rauma, opi ate medi cat ions, i ncreased i ntest i nal pressure) unl ess ot her techni ques
f or securi ng t he ai rway have f ai l ed. Hiatal herni a i s a rel at i ve cont raindi cat ion to
LMA use unless ef f ecti ve measures to empty t he stomach have been taken.
Pat i ents wi t h obesi t y may be candi dat es for the LMA (15,279,1250, 1306).
There i s disagreement about the saf ety of the l aryngeal mask f or procedures such
as l aparoscopi c surgery, where i nt ra-abdomi nal pressure i s hi gh (985,986).
Successful use of the LMA i n thi s si tuati on has been reported
(31,662,991,993,997,998,1307).
The pati ent wi t h gl ott i c or subglott ic ai rway obstruct i on, such as t racheomal acia or
external tracheal compressi on, should not be managed wi t h a l aryngeal mask,
because i t cannot prevent tracheal col l apse (756,1308).
Supragl ot t ic pathology such as a cyst , abscess, hematoma, or t issue di srupti on can
make proper posi t i oni ng di ff icul t or i mpossible (1309), al though t he LMA has proven
useful i n upper ai rway obstruct i on caused by supraglott ic edema, a t hyrogl ossal
t umor, and tonsi l l ar hypert rophy (147, 430, 655,656). A val lecul ar cyst has been
reported to cause obstruct ion af ter t he l aryngeal mask was i nsert ed (1310). If the
mask i s pushed behind the epigl ot ti s, vent i lat i on may be possi ble. It may
P. 493

be more appropri ate t o use al ternati ve i nserti on t echniques, dependi ng on the
nature of t he pathol ogy (19).
Maj or cervical pathol ogy such as a l arge goi ter, swel l i ng in t he hypopharynx, neck
f ibrosis, laryngeal cancer, or a devi ated t rachea may obstruct the ai rway and make
i ntubat ion t hrough an LMA dif f i cul t (331, 353,1311, 1312). The LMA-Fast rach may
have a higher success rate than the LMA-Cl assic i n these pat i ents (1313).
The LMA may be di f fi cul t or impossi bl e to i nsert i n pati ents wi th an angl e between
t he oral and pharyngeal axes of l ess t han 90 at the back of the tongue, a l i mi ted
mouth openi ng, pal atal def ects, oropharyngeal masses, a hard pal at e cri b f or thumb
sucki ng, and sharp edges i n the mout h (19,28,243,1314). I n pati ents who have had
cervi cal radiotherapy, LMA i nsert i on and subsequent venti l ati on may be extremel y
di ff i cul t (311, 1315). Whi l e i t has been stat ed t hat an i nterdental distance of 20 mm
of l ess precludes use of the LMA-Fastrach, i t has been used wi t h smal l er openi ngs
(28).
I n pati ents who requi re high i nf lati on pressures, that i s, t hose wi t h l ow compl i ance
or high resi stance, onl y the LMA-ProSeal shoul d be used.
Presence of a bl eeding disorder is consi dered a relative contrai ndi cat i on to using
an LMA (740,1129,1316).
Some f eel that the LMA i s rel ativel y cont raindicat ed in si tuat ions where there i s
rest ri cted access to the ai rway, especi al l y if t here is no guarantee that the LMA can
be repl aced i f i t becomes di sl odged or i f intubati on becomes necessary. The LMA
has been used i n the lateral and prone posi t i ons (291,1028,1252, 1317,1318).
Anesthesi a in t he prone posi t i on is hi ghl y controversi al . Regurgi tat ion i s more
l ikel y, and hi gher ai rway pressures may be needed. The LMA may be more easi l y
di spl aced i n thi s posi ti on.
Whi le some anesthesi a providers consi der prol onged procedures a cont rai ndicati on
t o t he LMA, t i me alone has not been shown to be a l imi ti ng f actor.
Requirement for Paral ysis or Obtunded Airway Refl exes in
Some Situations
The LMA cannot be inserted unless the j aw and pharynx are f ul l y rel axed.
Coughi ng, gaggi ng, vomi ti ng, bi t i ng, l aryngospasm, and bronchospasm can occur i n
i nadequatel y anestheti zed pati ents, especi al l y t hose wi th chronic respi rat ory
di seases and heavy smokers.
Lost Airway Management Skill s
The abil i ty to maintai n an adequate ai rway by usi ng a face mask is one of t he
f undament al skil l s of anestheti c practi ce. I ncreasi ng dependency on the LMA may
resul t i n a l ack of experi ence and skil l i n usi ng a face mask for prolonged peri ods
or wi t h a di f f i cul t ai rway (1320). I ntubat ion ski l l s may be compromi sed by t he
i ncreasi ng popul ari t y of the LMA (1320, 1321).
Loss of Tacti le Monitoring
Whi le t he laryngeal mask f rees the anest hesia provi der' s hands, i t di stances t he
provi der f rom t he pati ent and may cause del ay in diagnosi ng a decrement i n ai rway
quali t y.
Less Rel iable Airway
The LMA does not secure a cl ear ai rway as ef fecti vel y as a t racheal tube and does
not prevent ai r way obst ructi on at the gl ot ti c and subgl ott i c l evel s. The LMA can be
more readil y di spl aced than a t racheal tube. Movements of t he head, neck, or
drapes; i nserti on of a pack; and the li ke t hat would be acceptable wi th a t racheal
t ube i n place may cause LMA displ acement.
Unreliable Drug Admini stration
During resusci tati on, the t racheal t ube is someti mes used f or drug admi ni strat ion.
The LMA i s not as rel iabl e a rout e for admi ni steri ng drugs as i s the t racheal tube
(1322,1323).
Other Supraglottic Airways Similar to the Laryngeal
Mask
The success of the l aryngeal mask has caused a bewi l deri ng vari et y of ot her
supraglott ic devi ces t o be produced (2,1324). Some are si mi l ar to the LMA, whi l e
ot hers are disti nct . Some of t hese devi ces have undergone modif icat ions ei t her i n
materi al s or desi gn si nce thei r i ni ti al i ntroduct ion, so the reader shoul d make
cert ai n t hat perf ormance studi es of a parti cular devi ce do not rel at e to an ol der
versi on of t hat devi ce.
Soft Seal Laryngeal Mask
Description
The Port ex Sof t Seal Laryngeal Mask (Fi gs. 17.20, 17.21) i s a clear, disposable
mask made f rom pol yvi nyl chl ori de.
P. 494

The oval cuff does not taper at the t i p. The i nf l at i on tube is at tached to the ai rway
t ube. There i s a bl ue li ne on the convex surf ace. It has no epi gl ot ti c bars. I t is
avai l able i n a number of si zes, as shown i n Table 17.9. The maxi mum
recommended cuf f volume i s marked on t he pi lot bal loon. Some i nvest igators
recommend that a si ze 3 be used f or adul t f emal es and a si ze 4 f or adul t mal es
(1326). Ot hers have recommended si ze 4 f or adul t f emal es and si ze 5 f or adul t
mal es (1326).

View Figure

Figure 17.20 Back of the Soft Seal Laryngeal Mask.


View Figure

Figure 17.21 Front of the Soft Seal Laryngeal Mask. Note
the absence of bars between the tube and bowl.

Insertion
I nserti ng t he Sof t Seal wi t h a parti al l y i nf lated cuff has been f ound t o be easier and
l ess t raumati c that i nsert i ng t he device wi t h the cuff f ul l y def l ated
(541, 542,1325,1327,1328, 1329,1330). The i nsert i on procedure is si mi lar to t hat of
an LMA.
Evaluation
Most studi es show t hat t he Sof t Seal mask of f ers easy i nserti on and good cl i ni cal
perf ormance i n most adul ts and chi l dren
(541, 542,543,544, 1151,1330,1331,1332, 1333,1334,1335).
The cuff is l ess permeable t o ni t rous oxi de than si l icone masks, so t he i ncrease i n
cuff pressure resul t i ng f rom ni t rous oxi de di f f usion i s l ess than wi th those devi ces
(198, 199,540,541, 544, 1331,1336,1337). Intracuff pressure shoul d be moni t ored and
adj usted t o keep i t at 60 cm H
2
O (540).
I n one report ed case, compl et e ai rway obstruct i on occurred when a Sof t Seal
Laryngeal Mask was i nsert ed because the epi gl ott i s entered t he tube shaf t (1338).
No obstruct i on occurred when an LMA-Uni que was i nserted.
Comparison with Other Supragl otti c Airway Devices
Compari sons bet ween t he Sof t Seal and LMAs show conf l i ct i ng resul ts, possibl y
because i n some studi es, the Sof t Seal was i nserted wi th t he cuf f f ul l y def l ated
(1150,1332,1333,1334, 1335).
Most studi es compari ng t he LMA-Cl assi c and Sof t Seal found si mil ar f i rst t i me
i nsert i on rates and easy inserti on (541,544,1150, 1331,1336). Leak pressures were
comparabl e, wi th some studies report ing sl i ghtl y hi gher pressures wi th t he Sof t
Seal (1150) and others wi t h t he LMA-Cl assi c (544). The Sof t Seal Laryngeal Mask
was been found to have a lower or equal i ncidence of sore t hroat i n the i mmedi ate
postoperati ve peri od i n some but not al l studi es
(541, 1150,1325,1328,1330, 1331,1332,1339). When tracheal i nt ubati on through an
LMA-Classi c and a Sof t Seal Laryngeal Mask were compared, no si gni fi cant
di ff erence i n ti me to i ntubate or t he success rat e were f ound (1340).
When t he Sof t Seal was compared wi t h t he LMA-Uni que, some studi es showed
comparabl e i nsert i on rat es and t i mes (1150, 1337), whi l e one showed that short er
t i mes and f ewer at tempts at i nsert i on were needed wi t h t he LMA-Uni que (1333).
The ai rway l eak pressure was equal or hi gher wi t h the Sof t Seal
(1150,1333,1335,1336, 1341). Postoperat ive sore t hroat and mucosal t rauma was
more common i n t he Sof t Seal
P. 495

(1151,1334,1336,1338), al though the Sof t Seal and the LMA-Unique were f ound to
exert equal pressure on the mucosa (1343).
TABLE 17.9 Soft Seal Laryngeal Mask Sizes
Size Description Tube (I D in
mm)
Tube (OD in
mm)
Maximum Cuff
Volume (mL)
1 Neonates up to 5
kg

1.5 Infants 5 to 10 kg
2 Infant/child 10 to
20 kg

2.5 Child 20 to 30 kg
3 Child 30 to 50 kg 10.1 15.5 25
4 Adult 50 to 70 kg 11.0 17.6 35
5 Adult over 70 kg 12.0 19.8 55
ID, internal diameter; OD, outer diameter.


View Figure

Figure 17.22 Ambu Laryngeal Mask.

Ambu Laryngeal Mask
Description
The Ambu Laryngeal Mask (Fi gs. 17.22, 17.23) is a di sposabl e device t hat has a
cuff t hat i s tapered at t he tube. The ai rway t ube i s l arger and more rigid t han t hat of
t he LMA and is precurved. I t has no aperture bars. The inf l ati on l ine i s at tached to
t he ai rway t ube. It has a rei nf orced ti p. I t i s avai l abl e in seven si zes, as shown i n
Table 17.10. A reusabl e versi on is also avai l abl e i n ei ght sizes, f rom 1 to 6.
Use
Ni trous oxide wi l l di ff use t hrough t he cuf f , but t he i ncrease i s relat ivel y smal l (198).

View Figure

Figure 17.23 View of bowl of the Ambu
Laryngeal Mask.

TABLE 17.10 Ambu Laryngeal Mask
Size Patient Weight
(kg)
Maximum Cuff I nflation
Volume (mL)
1 Up to 5 4
1.5 5 to 10 7
2 10 to 20 10
2.5 20 to 30 14
3 30 to 50 20
4 50 to 70 30
5 70100 40
6 >100 50

I f intubati on becomes necessary, t he manuf acturer recommends t hat i t be
perf ormed over an ai rway exchange cathet er.
Intubating Laryngeal Airway
Description
The I ntubat i ng Laryngeal Ai rway (I LA) (Fi gs. 17.24, 17. 25) i s a reusable device
made f rom si l icone wi th a cl ear, curved tube and a dark bl ue, oval bowl . The bowl
has a downward ti l t at t he ti p to f aci l i tate i t sl i ppi ng bel ow the epi gl ottis. The
openi ng into the bowl has ri dges on the top and si des to prevent the epi glott is f rom
bei ng t rapped, resul ti ng i n a keyhol e-shaped out l et . There are ridges i n the bowl
bel ow t he outl et. These are desi gned to i mprove the seal and to help i sol ate t he
esophagus.
The I LA is avai l able i n three si zes (Table 17.11) and al l ows use of standard
t racheal tubes of ID 5.0 t o 8.5. It can be autocl aved up to 40 t i mes.
A reusabl e removal st ylet f or stabi l i zi ng the tracheal t ube whi l e t he ILA is bei ng
removed f ol lowi ng i ntubati on is avai labl e f rom the manuf acturer (Fi g. 17.26).

View Figure

Figure 17.24 Intubating Laryngeal Airway.

P. 496



View Figure

Figure 17.25 Bowl of the Intubating Laryngeal Airway.

Use
A jaw l i f t i s recommended when the devi ce i s inserted. Fi beropt ic gui dance f or
t racheal int ubati on produces the best resul ts.
Other Supraglottic Airway Devices
Laryngeal Tube Airway
Description
The Laryngeal Tube Ai rway (l aryngeal tube, LT) (Fi g. 17.27) i s a reusabl e si l icone
device that has a si ngl e l umen that i s cl osed at the ti p (1343,1344). Si ngl e-use
versi ons (LT-D) made of pol yvi nylchlori de are avai labl e. The Laryngeal Tube
Sucti on (LTS, Sonda laryngeal tube, SLT) (Fi g. 17. 28) has an addi ti onal
(esophageal ) l umen post eri or t o the respi ratory l umen that ends j ust distal to the
esophageal cuf f f or sucti oni ng and gast ri c tube placement (1345, 1346,1347).
The LT has a smal l (esophageal , distal ) cuff near t he bl ind distal ti p and a larger
(oropharyngeal , pharyngeal ) cuff near t he middl e of the tube wi th one i nf l ati on t ube
t o i nf l ate both l i ght bl ue cuf f s. Gas exchange is through t wo anteri or-f aci ng, oval -
shaped openi ngs (venti lati on hol es) bet ween t he two cuf f s. These al low sucti oni ng
or f i berscope passage. In addi t ion, t here are si de hol es l ateral to t he t op of t he
di stal openi ng (1348). A ramp l eads f rom the posteri or wal l t oward the mai n
venti l atory outl et (1349).
TABLE 17.11 Available Intubating Laryngeal Airways
Size Patient Weight (kg)Maximum Tracheal Tube Size
2.5 20 to 50 6.5
3.5 50 to 70 7.5
4.5 70 to 100 8.5

The ai rway tube is rel ati vely wi de and curved. There are three marks on t he tube
j ust bel ow t he connector t o the breathing system. These i ndi cat e the range f or
proper dept h pl acement. The tube si ze is col or coded on the connector, wi t h each
si ze havi ng a dif ferent col or. Tabl e 17.12 gi ves the si zes of avai l abl e l aryngeal
t ubes.
Use
For i nsert i on, the pat i ent ' s head is placed in t he neutral or sni ff i ng posi t ion. A j aw
t hrust may be helpful (1350). Bot h cuf fs shoul d be def l ated and a water-based
l ubricant appl i ed. Af ter t he t ube i s i nt roduced int o the mouth, the f l at edge of the ti p
i s placed against t he hard pal ate, keepi ng the tube centered. The t ube i s then sli d
al ong the pal at e and i nto t he hypopharynx unt i l resistance is f el t. A mal posi ti oned
LT wi l l of t en bounce back f rom the i ntended posi ti on (1351). Af t er i nserti on, the
marks on the shaf t shoul d be al i gned wi t h the teet h. If di f f i cul t y i s encountered, a
l ateral inserti on or a l aryngoscope may be hel pf ul .
The cuff s shoul d be i nf lated to a pressure 60 cm H
2
O (1352). The proxi mal cuf f wi l l
f il l f i rst . The volume requi red wi l l depend on t he pat i ent (1353). The manuf act urer' s
maxi mum recommended vol umes are shown i n Table 17.12 (see page 498). I f a
manometer is not avai l abl e, cuf f vol ume shoul d be adj usted so that t here is a sl i ght
oropharyngeal leak at the requi red vent i l at ory setti ng and t hen ai r shoul d be added
unti l the leak just
P. 497

di sappears. Af ter i nserti on and cuf f i nfl ati on, t he ai rway l eak pressure shoul d be
measured and epi gastri c auscul t at ion perf ormed (1354). If gast ri c i nfl ati on is
occurri ng, the cuff s should be i nf lated more. The devi ce may need to be moved up
or down to achi eve ef fecti ve venti l at ion.

View Figure

Figure 17.26 Removal stylet for stabilizing the tracheal
tube during removal of the Intubating Laryngeal Airway
following intubation.


View Figure

Figure 17.27 Laryngeal Tube Airway. The distal cuff
blocks the esophagus. (Courtesy of King Systems
Corporation.)

The LT can be used wi t h ei t her spont aneous breat hi ng or posi ti ve-pressure
venti l ati on (1355,1356,1357). Cuf f pressure shoul d be moni t ored cont i nuousl y. I f
ni trous oxi de is used, cuff pressure wi l l need to be readjusted duri ng the case
(1358,1359,1360).
For tracheal i ntubat ion, an ai rway exchange cat heter or t racheal tube mounted on a
f iberscope i s inserted t hrough the laryngeal tube and into the trachea (1361). If the
vi ew through the f i berscope i s not sat isfactory, the l aryngeal tube may need to be
rotated. A j aw t hrust may be helpf ul .
For nasotracheal i ntubati on, t he laryngeal tube is i nsert ed and a f i berscope wi th a
t racheal tube advanced through t he nose (1362,1363, 1364). The di stal cuff of the
l aryngeal tube hel ps to i denti f y the gl ot ti s, whi ch should be j ust i n f ront of i t. Af t er
t he tracheal t ube has ent ered the t rachea, t he l aryngeal tube is removed. The LT
has been used to smooth emergence in a pati ent wi t h a nasal int ubati on by
subst i tut ing the LT f or t he tracheal tube (1365).

View Figure

Figure 17.28 Laryngeal Tube Suction. There is an
additional (esophageal) lumen posterior to the respiratory
lumen that is open distal to the esophageal cuff. (Courtesy
of King Systems Corporation.)

The reusabl e l aryngeal t ube must be cl eaned and st eril i zed bet ween uses. It i s f i rst
washed i n warm wat er wi th soap or a mi l d det ergent . Tube brushes must be used to
cl ean t he venti l ati on channel and ai rway openi ngs. The t ube shoul d be i nspected to
determine t hat al l vi si bl e f orei gn matter has been removed. Prior to steri l i zat ion,
t he cuf fs must be evacuat ed of any ai r. The LT should be autoclaved at 134C
(273F) and 2. 4 bar (35 psi ) f or 10 mi nutes. These devi ces must not be steri l i zed
P. 498

by using f ormal dehyde, gl utaral dehyde, et hyl ene oxi de, or pl asma steri l izati on. The
manuf acturer recommends up t o 50 uses f or t he reusable devi ce (1366).
TABLE 17.12 Sizes of Laryngeal Tubes
Size Patient Weight (kg) Color of ConnectorMaximum Cuff Vol (mL)
0 Neonate <6 Transparent 15
1 Infant 6 to 15 White 40
2 Child 15 to 30 Green 60
3 Small adult 30 to 60 Yellow 120
4 Medium adult 50 to 90 Red 130
5 Large adult >90 Violet 150

Evaluation
The LT i s relat ivel y easy to insert, even f or cl i nicians who have l i ttl e or no
experience. The inserti on ti me is short, and the success rate f or f i rst-t i me i nserti on
i s high
(431, 1352,1355,1356,1367, 1368,1369,1370, 1371,1372,1373,1374,1375,1376). I t is
wel l t ol erated duri ng emergence (1367). Because the di st al cuff f i ts over the
esophageal i nl et , t he ri sk of gast ri c inf l at ion i s l ow (1377).
Sat i sfact ory venti l at ion wi t h both spont aneous and cont rol l ed venti l ati on can be
achieved i n most pati ents (23,1352,1356,1367,1368,1373,1378).
Hi gh venti lati on pressures can be used, and t he di stal cuff should seal t he
esophageal i nl et . Thi s device may be especi all y useful for resusci t ati on
(1352,1356,1366,1375, 1377,1379,1380,1381). I t has been used i n the cannot
i ntubate, cannot vent i late si t uat i on (1382) and in obstetrics af t er f ai led i ntubati on
(1383). I t has proved usef ul i n edentulous pat ients i n whom venti l ati on wi th a f ace
mask was dif f icul t (1384).
Al though a study f ound that the pati ent ' s head and neck stabi l izati on by manual i n-
l i ne method of t en made t he laryngeal tube ei ther dif f icul t or i mpossi bl e to i nsert
(1385), i t has been used wi t h manual in-l ine stabi l i zat ion and a high cervi cal col l ar
(1347,1364,1386).
The i nci dence of compl icati ons such as sore t hroat , mout h pai n, or dysphagi a
associ ated wi th i ts use i s l ow (1357,1367,1369,1370).
Cuf f rupt ure has been reported when a manometer was not used to eval uate cuf f
pressure (1387).
I n compari son wi th t he LMA-Cl assi c, i nsert ing the LT was easi er f or inexperi enced
personnel (1374,1388). Cases have been reported where the l aryngeal mask
i nsert i on f ai led but t he LT was successfull y i nserted (1363,1382, 1389). Duri ng
control led vent il ati on, the LT provi des hi gher seali ng pressures and ti dal vol umes
t han the LMA-Cl assic i n adul ts and chi l dren, and gast ri c i nf l at ion occurs l ess
f requent l y (432,1352, 1368,1374,1378,1390, 1391, 1392,1393). When used f or
spontaneous breathing, t he laryngeal mask provi ded successf ul ai rway
mai ntenance in more pat ients than di d the LT (1393, 1394). The i nci dence of
compl i cati ons i s si mil ar, al though the LT may requi re more posi ti on readj ust ments
t o obtain a cl ear ai rway (1343,1391). The LMA has a small er st orage capaci t y than
t he LT, so regurgi tated l i qui d is l ess l i kel y to be aspi rated wi th the LT (1395).
I n compari son wi th t he LT, the LMA-ProSeal was f ound to be easier to i nsert ,
i nsert ed successful l y on the f i rst attempt more of ten, and gave a si gni fi cantl y bet ter
vi ew of the gl ot ti s (466,1396). Duri ng cont rol l ed venti l ati on, the t wo devices
perf ormed equal l y wel l i n terms of seal pressure (1396). Duri ng spontaneous
breat hi ng, t he LMA-ProSeal was successful more of t en (466).
When t he LT-Suct i on and the LMA-ProSeal were compared, both devi ces performed
equal l y wel l i n terms of seal pressure and successful inserti on, but the LMA-
ProSeal caused l ess hemodynamic st ress, was associ ated wi t h bet ter vent i lati on,
and al l owed a bet t er vi ew of t he larynx wi t h a fi berscope (1396,1397,1398, 1399).
I n compari ng the i nt ubat i ng LMA and LT duri ng manual i n-l ine neck st abi l i zati on,
pl acement was easi er and qui cker and ti dal vol ume great er wi th t he LMA-Fast rach
(1400).
Perilaryngeal Airway
Description
The Peri laryngeal Ai rway (CobraPLA
TM
, CPLA
TM
, Cobra PLA
TM
) (Fi gs.
17.29,17.30,17.31) i s a singl e-use plasti c device wi t h a wi de, tapered pat ient end
t hat has a seri es of sl ots. It has a hi gh-vol ume, l ow-pressure, oval cuf f that i s
shaped t o f i t in the hypopharynx at t he base of the t ongue. I t i s avai l abl e in ei ght
si zes (Table 17.13).
Use
Bef ore use, t he t ube shoul d be checked f or def ects and the cuf f f or l eaks. Lubri cant
shoul d be appl i ed to the ent i re cuf f and t he back and si de of the pat i ent end. The
cuff shoul d be def l ated and f ol ded back agai nst the tube.
P. 499



View Figure

Figure 17.29 Perilaryngeal Airway. It has a high-volume,
low-pressure oval cuff that is shaped to fit in the
hypopharynx at the base of the tongue. It is available in
eight sizes (Table 17.13).

The pati ent should be pl aced i n a sni f f i ng posi t i on. A j aw t hrust may f aci l i tate
i nsert i on (1401). The devi ce i s i nserted strai ght back i nto t he mouth, not di rected
t oward t he hard pal ate. The tube i s advanced bli ndly i n the mi dl ine unti l resi stance
i s fel t .
The cuff should be i nf lat ed wi th j ust enough ai r t o obtai n an appropri ate seal . Cuf f
pressure shoul d be less than 25 cm H
2
O. If t here i s a l eak, the device shoul d be
pushed i n sl ightl y and ai r added to t he cuf f or t he uni t removed and repl aced wi th a
l arger si ze. It may be necessary to move the device up or down t o obtai n
sati sf actory vent i l at i on (1402).
During use, ai rway pressure shoul d be li mi ted to less than 20 cm H
2
O.
A tracheal tube can be inserted t hrough t he Cobra PLA. Up to an 8-mm ID tube can
be used wi t h a Cobra 4, 5, or 6. For si zes 2 and 3, a 6. 5-mm t racheal tube wi l l f i t .
Evaluation
The Cobra i s easy t o insert and i s associ ated wi t h a hi ghl y successf ul f i rst inserti on
rate wi th a l ow i ncidence of sore t hroat i n adul ts and pediatric pati ents
(1043,1401,1402,1403, 1404,1405,1406).

View Figure

Figure 17.30 Side view of the Perilaryngeal Airway.

The l arge lumen makes i t useful for passing a rel at ivel y l arge tracheal t ube or
f iberscope, maki ng i t usef ul for assessi ng the ai rway (1407,1408,1409). The short
breat hi ng tube al lows a standard l ength t racheal tube wi t h i ts cuf f to pass wel l past
t he vocal cords. The Cobra does not need to be removed af t er i nt ubat i on.
The ai rway seali ng pressure has been f ound t o be hi gher and the l aryngoscopic
vi ew superi or wi t h t he Cobra compared wi t h the LMA-Cl assic
(1403,1407,1410,1411, 1412). The seal i ng pressure i s also hi gher t han wi th t he
LMA-Uni que (1413).
I t has been used f or percutaneous dil atat ional cri cothyroi dotomy (1414), i n the
di f f icul t to i ntubate/dif fi cul t t o venti late scenari o (1415), i n t wo cases of f ace and
neck cont ractures when an LMA-Cl assi c fai l ed (1416), and af t er LMA-Fastrach
f ai l ure (1417).
The Cobra PLA does not protect agai nst aspi rat ion (1418,1419, 1420). Ai rway
obstruct i on has been report ed when t he Cobra apparentl y moved upward, catchi ng
t he
P. 500

epi gl ot ti s bet ween t he bars (1421). Cuf f l eaks have been report ed (1422).

View Figure

Figure 17.31 Patient end of the Perilaryngeal Airway.


View Figure

Figure 17.32 Streamlined Pharynx Airway Liner. T, toe; B,
bridge; H, heel. (Courtesy of ARC Medical, Inc.)

Streamlined Pharynx Airway Liner
Description
The St reaml i ned Pharynx Ai rway Liner (SLIPA
TM
) (Fi gs. 17.32, 17.33) is a pl asti c,
di sposabl e, uncuff ed device that is anatomicall y preshaped to l i ne the pharynx. It
f orms a seal wi th t he pharynx at the base of t he tongue and the entrance to the
esophagus by vi rtue of the resi l i ence of i ts wal l s.
The dist al part of t he SLI PA i s shaped l ike a holl ow boot wi t h a toe, bridge, and
heel . There is an anteri or openi ng for vent i l at i on. The end of the toe rests i n the
esophageal ent rance. The bri dge f i ts i nto t he pyrif orm f ossae at t he base of the
t ongue, whi ch i t di spl aces f rom the posteri or pharyngeal wal l . The heel connects to
t he ai rway t ube, whi ch is rect angul ar i n shape and has a col or-coded connector.
The heel serves to anchor t he SLIPA in a stabl e posi t i on. Accordi ng to the
manuf acturer, i t usuall y does not need to be f ixed i n place. The SLIPA has a l arge-
capaci t y chamber f or stori ng regurgi tated l iqui ds.
Toward t he toe side of the l ateral bul ges of the bri dge are smal l er secondary l ateral
bul ges. Thi s f eat ure i s meant to reli eve pressure at this si te and to prevent damage
t o t he hypogl ossal and recurrent l aryngeal nerves.
TABLE 17.13 Perilaryngeal Airways
Size Tube (I D in mm) Patient Weight (kg) Cuff Volume (mL)
0.5 5.0 >2.5 <6
1 6.0 >5 <10
1.5 6.0 >10 <22
2 10.5 >15 <40
3 10.5 <35a <50
4 12.5 <70a <60
5 12.5 <100a <60
6 12.5 >130 <85
ID, internal diameter.
a
Another source suggests size 3 for patients <60 kg; size 4 between 60 and 80 kg; and
size 5 >80 kg (1402).

The SLIPA i s avai l abl e in si x adul t si zes that rel ate t o the di mensi on across the
bri dge: 47, 49, 51, 52, 55, and 57 mm. To choose the correct si ze, thi s di mensi on
shoul d be matched to t he wi dth of the pati ent ' s thyroi d cart i l age.
Use
The SLIPA shoul d be exami ned f or defects and water-sol ubl e l ubri cant appl i ed. It
shoul d be col lapsed i n the anteri or-posteri or pl ane bef ore i nserti on. Af ter i nsert i on,
i t spontaneousl y ret urns to i ts prei nsert i on shape.
The head is extended and the devi ce inserted toward the back of t he mouth unt i l
t he heel locates i tsel f i n the pharynx. It i s hel pf ul i f t he jaw i s l i f ted f orward duri ng
i nsert i on. A l aryngoscope or gl oved f i ngers can be used to create a space i n the
pharynx (1049).
Ai rway seal pressure should be checked af ter i nsert i on. If i t is too l ow, a l arger si ze
SLI PA shoul d be t ri ed. If posi tive-pressure venti l at ion i s used, t he epi gastrium
shoul d be auscul tated to make certain t hat gast ri c i nfl ati on i s not occurri ng (1049).
I f obstructi on i s encountered i mmediatel y af ter i nserti on, a downf ol ded epi gl ot ti s
may be t he cause. The head shoul d be extended and the j aw pul l ed f orward. I f t hi s
does not correct the probl em, the SLIPA shoul d be removed and reinserted wi th an
accentuat ed j aw l i f t .
P. 501

Another maneuver i s to momentari l y i nsert t he SLIPA deeper so that i t wi l l f ree up
t he epi gl ott i s. If this does not rel i eve the obst ructi on, the l i kel y cause is
l aryngospasm.

View Figure

Figure 17.33 Streamlined Pharynx Airway Liner in place.
T, toe; B, bridge; H, heel. (Courtesy of ARC Medical, Inc.)

I f regurgi t ati on i s suspected, a sucti on cathet er wi t h t he curve to one si de shoul d
be i nsert ed so that i t does not t ouch t he vocal cords.
I t i s recommended t hat t he SLI PA be used wi t h the head i n the neutral posi t i on
because t wi st ing the head to one si de may di sl odge the seal . Parti al obst ructi on
duri ng spontaneous vent il at i on wi l l usual l y be rel ieved by extensi on of t he head or
si mpl y by inst i tut ive posi ti ve-pressure vent il at ion.
Evaluation
The SLIPA i s easy t o i nsert and i s associ ated wi t h a high f i rst i nsert i on success
rate even in i nexperienced hands (1423,1424). Despi te i ts i rregul ar shape, i t
i mposes no more resi st ance than si mi l ar supragl ot ti c devices (1425). I t can be used
wi th both spont aneous breat hi ng and control l ed venti l at ion. I t is tol erated wel l
duri ng recovery (1424). The ai rway seal i ng pressure i s greater than wi t h the LMA-
Cl assic (1049). Because there i s no cuf f , ni trous oxi de has no eff ect on seal i ng
pressure.
Bot h the SLIPA and t he LMA-ProSeal but not the LMA-Cl assic provide eff ect ive
protect ion agai nst aspi rati on duri ng posi tive-pressure vent i l ati on (1049). However,
i t is possi bl e that t he storage capaci ty of the SLIPA may not be adequat e f or non-
f ast ed pati ents. The manufacturer suggests that i t may be saf e to suct ion wi t hin t he
device if regurgi tated l i qui d is present wi th negl igi bl e ri sk of precipi tat ing
l aryngospasm.
The SLIPA i s cont raindicat ed if upper ai rway anatomy i s abnormal or di storted (1).
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P. 519


Questions
For the f ol lowing quest ions, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i s D i s correct
i f A, B, C, and D are correct .
1. Uses for the fl exible LMA i ncl ude
A. I ntubat i ons through the LMA
B. When a mouth gag i s in place
C. Si tuat ions where l ow resi st ance t o f l ow i s needed
D. Surgi cal procedures around the head and neck
Vi ew Answer2. Checki ng the LMA before use should i ncl ude the
foll owi ng:
A. The i nf l ated cuf f shoul d hold pressure f or at l east 2 mi nut es
B. Ai r shoul d be wi t hdrawn t o reveal l eaks i n t he cuf f
C. The bars shoul d be probed to be certain t hat they are i ntact
D. The t ube shoul d be fl exed more than 180 degrees
Vi ew Answer3. To prepare the LMA for use,
A. Both si des of the cuff shoul d be l ubricated
B. The cuf f should be wri nkl e-f ree
C. Lubri cants t hat contai n si l i cone are recommended
D. The cuf f should f orm a st if f wedge
Vi ew Answer4. If there i s difficul ty i n inserti ng the LMA, helpful
maneuvers i ncl ude
A. I nsert ing the LMA backward
B. Posi ti ve-pressure venti l ati on
C. I nsert i on f rom the si de of t he mouth
D. Cricoi d pressure
Vi ew Answer5. When cleaning and steri lizi ng the LMA,
A. I t shoul d f i rst be washed wi t h det ergent and wat er
B. The LMA can be steri l ized by usi ng the st eam autocl ave
C. Ethyl ene oxi de should not be used t o steri l i ze the LMA
D. The LMA can be soaked i n l i qui d chemi cal agents f or up to 30 mi nutes
Vi ew Answer6. Which statements are correct?
A. Dead space is great er wi t h t he LMA than wi t h the f ace mask
B. The pharynx adapts to the shape of the LMA cuf f
C. The rei nf orced LMA off ers less resistance to breathi ng than t he standard versi on
D. The work of breathi ng wi t h t he LMA is simi lar to t hat associated wi t h a t racheal
t ube
Vi ew Answer7. Indi cati ons for use of the laryngeal mask i nclude
A. Fai l ed i ntubat ion
B. Faci al burns
C. Prof essi onal si nger
D. Li mi ted mouth openi ng
Vi ew Answer8. If the LMA is used for ophthal mologic surgery,
A. I nt raocul ar pressure i s l ess duri ng inducti on and emergence wi t h the LMA t han
wi th a tracheal t ube
B. The LMA i s more l i kel y to be di sl odged duri ng surgery t han a t racheal tube
C. There i s l ess l i kel i hood of coughi ng during the surgi cal procedure
D. The standard LMA shoul d be used
Vi ew Answer9. Procedures to be performed if gastri c contents appear i n
the LMA i ncl ude
A. A 30-degree head-down posi ti on
B. Removal of the LMA f or suct ioning
C. I nsert i on of a tracheal t ube i f aspi rat ion has occurred
D. Pl acement of the pati ent i n the lateral posi ti on
Vi ew Answer10. What measures can be taken to mini mize the i nci dence
of aspiration?
A. Overi nf lati ng the LMA cuf f by 10 cc
B. Usi ng l ow ti dal vol umes
C. Keepi ng peak ai rway pressure l ess than 41 cm H
2
O
D. A l evel of anesthesi a adequat e to prevent swal l owi ng
Vi ew Answer11. Causes of ai rway obstruction associated with the LMA
i ncl ude
A. Backf ol di ng of the di stal cuf f
B. Laryngospasm
C. Obstructi on of t he laryngeal openi ng by the di stal cuff
D. Overdist ensi on of the cuf f
Vi ew Answer