LMA Placement

I have heard that people have a love and hate relationship with laryngeal mask airways (LMA). Lately, I have been using a lot of LMAs and the more I use them, more I like them. There are a few tricks to remember while placing one to avoid causing trauma even though micro trauma is frequent. There a variety of LMAs that I have seen at the sites I have been. LMA Supreme is my favorite (2nd picture) and has been the easiest to insert for me. However, a problem that can occur with any one of these is catching of the tongue in the opening of LMA as you are inserting it. Some patient's have large oral opening that make it easier to insert but for smaller oral opening it is important to make sure you protect the tongue.

Insertion:

One technique to help with this is to use a 4x4 gauze and hold tongue upward out of the mouth and slide the LMA over it. It can be helpful but hasn't always worked for me. Another technique I have used lately is to go in slightly sideways while inserting. I have found this technique to work better if I use the LMA exactly like its packed, without deflating the cuff. Once you get past the tongue enough, turn it straight again and your patient was saved from getting a frenulectomy.

Cuff air:
This is another thing to experiment with while inserting LMAs. I always go back and forth between deflating the cuff completely or adding in more air before insertion. The problem I have with deflating cuff completely is that its tip will almost always tend to bend on its itself and be a reason for some major struggle. So, based on my experience with them, a little bit of air always makes it easier. Now I just inflate it enough where there are no wrinkles or dips in the cuff and its worked quite well.

Anesthesia depth:
This is what makes us different from any random person trying to shove a mask down people's mouth. Figuring out how deep you need to have the patient prior to inserting the LMA may need a lot of practice especially if you like your patient to start breathing spontaneously immediately after insertion. Well, I have noticed that there is a very fine line between you having the patient too deep that they won't breath or them biting your finger when you are trying to make sure LMA's tip doesn't bend or worse...bronchospasm. Style points for putting the LMA in without patient coughing or gagging and then them breathing. However, I think its safer to give enough to have them go apneic and support their breathing until necessary either manually or with PS <20 on the vent. So, do give them the needed propofol dose! Use of opioids can also ease insertion but their administration should be very well timed. This is especially true if you are using fentanyl. There have been times when I am just a little bit delayed in pushing that fentanyl and then had to deal with them being way too comfortable to breath. Give fentanyl first thing as the patient enters the room. Sometimes, if a young, healthy person, I will even give it with the versed in preop and then bring to the OR.

Extubation:
This is one step of using LMA that I haven't seen many variations of. Almost all of the CRNAs or MDAs I worked with remove this without deflating the cuff. This prevents secretions from falling off the cuff and possibly be a reason for laryngospasm or bronchospasm.

Thats been my experience so far with LMAs. Very nice tool to use but if ever question using it in a patient that might possibly be more at risk than benefit from LMA...just intubate!! Better be safe than sorry. Hope you all liked this post. Let me know your experiences or suggestions.


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