Documente Academic
Documente Profesional
Documente Cultură
of the mask at an angle probably determined by the extent of the LMA. The adequate depth of anaesthesia for LMA
to which passage of the mask has deflected it down-wards. placement is significantly less than that for tracheal
When inflated, it lies with the tip resting against the upper intubation.
esophageal sphincter, the sides facing the pyriform fossae
Several insertion techniques have emerged to
with the upper surface behind the base of the tongue and the
complement the original technique which was described
epiglottis pointing upwards. The aperture of a properly
when the LMA was introduced. The standard technique
positioned LMA aligns itself anatomically with the laryngeal
involves a completely deflated LMA, held like a pen guided
inlet.
into the pharynx with the index finger of the operator at the
The tip of the LMA cuff lies at a variable depth junction of the tube and the bowl, with the operator at the
behind the cricoid cartilage; and the posterior surface head of the patient and the LMA aperture facing caudally.
immediately anterior to the C2 to C7 cervical vertebrae. With the head extended and the neck flexed by using the
The laryngeal inlet can be tipped anteriorly by the inflated hand under the occiput, under direct vision, the tip of the
LMA cuff when cricoid pressure is applied; this may explain cuff is pressed upwards against the hard palate. The LMA
why blind intubation via the LMA is more difficult with is advanced into the hypopharynx till a resistance is felt.
cricoid pressure applied. The cuff is then inflated with just enough air to seal, to
intra cuff pressure around 60 cms H2O. A common alternative
Indications
technique popular in children described by McNicol, consists
• Elective short surgical procedures under general
of inserting a partially inflated LMA into the pharynx above
anaesthesia excluding head and neck surgery
the epiglottis with the aperture facing cranially, the LMA
• Rescue airway in “cannot intubate – can ventilate” is then turned 180 degrees before advancing it into its final
and “cannot intubate, cannot ventilate” scenario if position. 11
the problem is supraglottic in nature, since successful
use of the LMA does not require the constellation of The LMA should then be secured after insertion in
factors required for direct laryngoscopy and such a way, so as to prevent rotation and movement
tracheal intubation.1,5,9 In 1996 it entered the American cranially. If surgical access allows, a preferred way to
Society of Anesthesiologists’ difficult airway connect the LMA to the anaesthesia circuit is to direct the
algorithm in five different places, both as a ventilatory circuit connection caudally and bring the circuit limbs down
device (airway) and a conduit for endotracheal on the side of the patient’s neck and head.
intubation. 1,2,8,9 Signs of correct LMA placement4,8,9
• Cardiopulmonary resuscitation1,7,8 a. Slight outward movement of the tube upon LMA
Contraindications2,4 inflation.
• Mouth opening less than 1.5 cm b. Presence of a small oval swelling in the neck around
• Poor lung compliance the thyroid and cricoid area.
• Airway pressure more than 20 cm of H2O c. No cuff visible in the oral cavity.
• Non fasting patients d. Expansion of chest wall on bag compression
Insertion technique1,2,4,7,9,10 Before taping the LMA in place, a bite block is
LMA insertion can be considered in the context of inserted to stabilize the LMA and prevent tube occlusion.
swallowing both in terms of the space it occupies and the
type of reflex response it elicits. The insertion technique Emergence technique
does not require the use of a laryngoscope or muscle Removal of the LMA can be accomplished either
relaxants and is designed to imitate the mechanism whereby during deep anesthesia or after protective reflexes have
the food bolus is swallowed. returned. 4,7,8
Preparation of the LMA and the patient is essential Pathophysiology
for successful placement. Lubrication of the mask should
Pharyngeal microcirculation is unimpaired at low
avoid the use of local anesthetics in order to preserve
to moderate cuff volumes for all LMA devices (except
protective reflexes against aspiration. A selection of LMA
intubating LMA). The LMA is a relatively noninvasive
sizes should be available in addition to the one most likely
airway compared with a tracheal tube, and it causes minimal
to fit because the anatomical features of the larynx cannot
disturbance of the cardiovascular and respiratory system.
always be predicted from the physical examination. Most
The incidence of sore throat is minimal because the cords
of the induction agents can be used to facilitate placement
SOOD : LMA VARIANTS 277
are not penetrated. The haemodynamic stress response to in 1992 to prevent tube occlusion,
LMA insertion is less pronounced than during tracheal improve surgical access and prevent
intubation during induction, maintenance and emergence from cuff displacement during head, neck
anaesthesia. Less anaesthetic is required to tolerate the and oropharyngeal surgery.4
LMA once the device is insitu. 1,8
It is made from medical
LMA and aspiration grade silicone and rubber and is
Although the correctly placed LMA tip lies against reusable. It consists of a Classic
the upper esophageal sphincter, the LMA does not isolate Fig. 2 : Flexible LMA LMA connected to a flexible, wire
the respiratory tract from the gastrointestinal tract and reinforced tube that is longer and
does not protect the lungs from regurgitated gastric contents. narrower than the Classic LMA. The wire reinforcement
The glottic seal is usually lost at peak airway pressures prevents kinking, the additional length allows the anaesthesia
above 20 cms H2O. 1,4 Incidence of aspiration with the breathing system to be connected further from the surgical
LMA is 2 per 10,000. 1 field and the reduced diameter allows more room in the
mouth. It is preferable for intra-oral surgery especially
LMA and the difficult airway1,2,7,8
adenotonsillectomy.
Several design features make possible its use as an
airway intubator, like the wide bore of the LMA tube, the The cuff and inflation line are identical to the Classic
width and elasticity of the aperture bars, the angle at which LMA. It is available in six sizes 2, 2.5, 3, 4, 5 and 6.
the tube enters the bowl of the mask, anatomic alignment
of the LMA aperture with the glottis and the low pressure II. The intubating LMA - Fastrach2,5,8
seal allowing synchronous patient ventilation. Since the Classic LMA
was not ideally suited to aid (blind)
However there are several problems associated with
tracheal intubation, the primary
this. The internal diameter of the airway tube is too small
design goal for a new intubating
to accommodate a normal sized tracheal tube, and it is too
LMA was to produce an intubating
long to ensure that a normal length tracheal tube will
system that eliminated the need
penetrate the vocal cords. The mask aperture bars interfere
for anatomical distortion and that
with the passage of the tracheal tube. Removal of the LMA
did not require manipulation of
may be difficult after successful intubation due to the length
the head and neck, and thus
of the airway tube. Direct blind intubation has a success
increased its utility in patients
rate around 55%. Success is reduced by cricoid pressure, Fig. 3 : Intubating LMA with cervical spine pathology. It
and is similar for normal and abnormal airways.
was released in 1997.
Fiberoptic guided intubation via the LMA has higher
success rate and causes less trauma. It can be performed It consists of three parts – the ILMA itself, the
directly by inserting the tracheal tube over the fiberoptic tracheal tube and a stabilizing rod.
scope or indirectly using a guide first. The ILMA is a rigid, anatomically curved airway
The manufacture’s warranty for LMA classsic is for tube made of stainless steel with a standard 15 mm
40 uses, but deterioration in performance does not occur connector. The tube is wide enough to accommodate an 8.0
until 80-100 uses. Despite high capital costs, the LMA is ETT and short enough to ensure passage of the ETT beyond
cost effective compared to tracheal tube.8 the vocal cords. A rigid handle attached to the tube facilitates
one handed in sertion, removal, and most importantly,
LMA variants adjustment of the device’s position so that the aperture
At present, variations include a reinforced/ flexible directly opposes the larynx. It has a single flap, the epiglottic
LMA (LMA-Flexible), LMA specifically designed for elevating bar.
tracheal intu-bation (LMA-Fastrach), single-use LMA It is available in three sizes (3,4,5) that correspond
(LMA-Unique) and LMA with an integral gastric access/ to the cuff size of the original LMA. After adequate
venting port (LMA-ProSeal). lubrication insertion of the ILMA may be easier than the
original LMA because the rigid tube follows the anatomic
I. Flexible laryngeal mask airway (reinforced LMA) 2,7,8
curve of the palate and posterior pharyngeal wall and one’s
In 1990, two reports appeared in the journal index finger does not have to enter the mouth. Once
‘Anaesthesia’ describing kinking of the LMA tube. The positioned correctly, the ILMA can be connected to a circuit
flexible LMA (fig. 2) was designed by Brain and released and used as an airway device. There are several maneuvers
278 PG ISSUE : AIRWAY MANAGEMENT INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005
to facilitate ILMA guided intubation, of which the seal thicker. It is supplied sterile and for single use only. It is
optimization (Chandi’s maneuver) consists of two sequential currently available in sizes similar to the Classic LMA.9
steps: obtaining the best seal by moving the cuff in the
pharynx in the sagittal plane, and then using the handle to IV. ProSeal Laryngeal mask airway (LMA ProSeal)4,5,8,9,13
slightly lift (and not tilt) the ILMA away from the posterior The ProSeal LMA is the most complex of the
pharyngeal wall. specialized laryngeal mask devices. It was designed by
Archie Brain in the late 1990s and released in 2000. The
It is recommended strongly that the special supplied
primary design goal was to construct a laryngeal mask with
ETT be used for intubation. This sili-cone tube is soft
improved ventilatory characteristics that also offered
tipped, straight, wire reinforced and cuffed. It exits the
protection against regurgitation and gastric insufflation. The
ILMA at an angle that facilitates passage through the glottis.
principal new features are a modified cuff and a drain tube.
Tracheal tubes available are 7.0, 7.5 and 8 mm internal
The ProSeal LMA is a double mask, forming two end-to-
diameter and each fits through each of the three ILMA.
end junctions: one with the respiratory tract and the other
To remove the ILMA once the trachea is intubated, with the gastrointestinal tract.
one should remove the 15-mm ETT connector while the
ETT cuff remains inflated. Then swing the ILMA out of the
pharynx and mouth while applying counter-pressure to the
ETT. To hold the ETT tube in place, the stabilizing rod (20
cm) is opposed to its proximal end, which effectively
increases the length of the ETT and permits sliding of the
ILMA out of the mouth.
LMA C Trach 12
LMA C Trach is a Fig. 7 : ProSeal LMA
modification on the “blind
Concept and Design8,9,13
on blind” technique of the
LMA Fastrach with The ProSeal LMA is made from medical-grade
integrated fibreoptics. silicone and is reusable. The mask and inflation lines are
identical to the Classic LMA. The cuff has identical
It provides a direct proportions but different dimensions among sizes. The larger
view of the larynx with real ventral cuff is attached to a second cuff placed on the
Fig. 4 : LMA C Trach
time visualization of the dorsal surface of the bowl.
tracheal tube passing through the vocal cords. It has two
Mask design is also unique. The bowl is deeper and
integrated fiberoptic channels – a light guide to transfer
has no aperture bars and the inflatable portion extends
light to illuminate the larynx and a 10,000 pixel image
around the back. When inflated, the mask is pushed
guide to transfer the image of the larynx to the viewer.
anteriorly and the glottis becomes enveloped in the bowl,
There is a modified epiglottic elevating bar which in contrast to the original design, in which the LMA and
optimises the light source and enables uninteruppted image the glottis opposed each other and the aperture bars prevented
transmission to the viewer. the glottis from herniating into the bowl. There is a flexible
It is fully autoclavable unlike conventional endoscopes wire reinforced airway tube, and because of their concern
and is yet to be introduced in India. for gastric distention with positive pressure ventilation,
ProSeal has an integral gastric access/venting port and a
III. The disposable LMA (UNIQUE)8 (fig. 5) tube which traverses through the PLMA bowl. When properly
It was synthesized and released positioned, the distal orifice of this drain tube lies in the
in 1998 for cardiopulmonary upper esophagus. Sealed off from the glottis, the esophagus
resuscitation because the silicone based and stomach can be vented to air or a 14-F sump tube can
Classic LMA was too expensive and be passed through the drain tube and gastric contents
needed proper sterilization to prevent evacuated. There is a plastic supporting ring around the
cross infection for this rare indication. distal drain tube to prevent the drain tube collapsing when
The disposable LMA is made of clear the cuff is inflated.
medical grade polyvinyl chloride. The A drain tube distal aperture that slopes anteriorly
Fig. 5 : Disposable LMA
airway tube is more rigid and the cuff allows the deflated tip to form a fine leading edge for
SOOD : LMA VARIANTS 279
Like the Classic LMA, remove when the patient obeys References
commands.8,13 1. Brimacombe JR., Berry AM. The Laryngeal Mask Airway. In: The
Difficult Airway I. Anesthesiol Clin N Am June 1995; 13(2): 411-37.
Physiology 2. Rasanen J. The laryngeal mask airway – First class on Difficult Airways.
The upper esophageal sphincter function is relatively Finnanest 2000; 33(3): 302-05.
unimpaired. The drain tube provides easy access to the 3. Pollard BJ, Norton ML. Principles of Airway Management, In: Wylie
gastrointestinal tract for monitoring of cardiac output, gastric and Churchill – Davidson’s (ed), A Practice of Anesthesia (7th Edn),
2003; 28: 445-46.
volume / pH and core temperature. Cardiovascular responses
4. Rosenblatt WH. Airway Management. In: Barash PG, Cullen BF,
and peak airway pressures are similar to the Classic LMA Stoelting RK. (eds) Clinical Anesthesia (4th Edn) 2001; 23: 599-605.
and are unaffected by cuff volume or tidal volume.8,13 5. Bogetz MS. Using the laryngeal mask airway to manage the difficult
Caution airway. In: The Upper Airway and Anesthesia. Anesthesiol Clin N Am
Dec. 2002; 20(4): 863-70.
• The ferromagnetic material present in LMAs can
6. Verghese C, Brimacombe JR. Survey of laryngeal mask airway
reduce image quality and even cause heating and Usage in 11, 910 patients: Safety and efficacy for conventional and
movement when used in MRI.8 nonconventional usage. Anesth Analg 1996; 82: 129-33.
• N2O rapidly diffuses into the air filled cuff, causing 7. Dorsch JA, Dorsch SE. (eds). Laryngeal Mask Airways. In Understanding
Anesthesia Equipment (4thEdn), Williams and Wilkins 1999; 15: 463-504.
a doubling of intra cuff pressure within 1-2 hours.8
8. Brimacombe JR. In: Laryngeal Mask Anesthesia - Principles and Practice
Sterilization (2nd Edn), Saunders, Philadelphia 2005.
The LMAs and their accessories are supplied 9. Khan RM(ed). Supraglottic airway devices. In: Airway Management –
Made Easy. A manual for Clinical Practitioners and Examinees. Paras
unsterile, and must be cleaned by hand washing or automatic Medical Publishers, Hyderabad, 2005; 12: 82-95.
washers and autoclaved at 135°C for 3-4 minutes 10. Ovassapian A, Meyer RM. Airway Management. In: Longnecker DE,
(pre-vacuum and wrapped). The cuff should be fully Tinker JH (eds) Principles and Practice of Anesthesiology (2nd Edn),
deflated and dry before autoclaving. ProSeal requires more Mosby : Philadelphia, 1998; 49: 1076-78.
attention. A small pipe cleaner should be used to clean the 11. McNicol LR. Insertion of the laryngeal mask airway in children.
Anaesthesia 1991; 46: 330.
drain tube and deflation of the ProSeal cuff requires the
12. http://www.LMACO.com. Instruction manual for LMA.
deflation tool since residual air can accumulate in the
13. Brimacombe J, Keller C. The ProSeal laryngeal mask airway. In: The
dorsal cuff.7,8 Upper Airway and Anesthesia. Anesthesiol Clin N Am Dec. 2002; 20:
871-91.
Conclusion
14. Sharma B, Sahai C, Bhattacharya A, Kumra VP. Our experience with
Classic LMA along with its variants, flexible LMA, ProSeal Laryngeal Mask Airway : A study of 200 consecutive patients.
ILMA, disposable LMA and ProSeal are now indispensable J Anaesth Clin Pharmacol 2004; 20(1): 51-57.
in the armamentarium of airway management devices.