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Using the Laryngeal Mask Airway

Using the Laryngeal Mask Airway. Norman L. Goody, MD. Using the LMA LMA and the Difficult Airway LMA and Pediatric Anesthesia LMA and OB Anesthesia Advantages of Using the LMA. Disadvantages of the LMA Complications Arising from Use of the LMA Contraindications to Using the LMA.

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Using the Laryngeal Mask Airway

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  1. Using the Laryngeal Mask Airway Norman L. Goody, MD

  2. Using the LMA LMA and the Difficult Airway LMA and Pediatric Anesthesia LMA and OB Anesthesia Advantages of Using the LMA Disadvantages of the LMA Complications Arising from Use of the LMA Contraindications to Using the LMA Objective

  3. History of the LMA development began in 1981 at Royal London Hospital by Dr. Archie Brain modification of the Goldman Dental Mask available commercially in UK since 1988 and in the US since 1992 now used in >50% of general anesthetics in some centers in UK (and probably US, too- especially ambulatory surgery)

  4. Characteristics of the LMA • Latex free, medical-grade silicone • Aperture bars • Sizes #1 <6.5 kg 2-5 ml #2 6.5-25 kg 7-10 ml #2 1/2 20-30 kg 14 ml #3 25-70 kg 15-20ml #4 70+ kg 25-30ml

  5. Using the LMA • Preparation of the LMA • Check patency of cuff • Lubricate POSTERIOR surface only • Surgilube v. lidocaine jelly • Induction • Insertion of the LMA • Common Problems • Cricoid Pressure • Securing the LMA

  6. Using the LMA • Maintenance of Anesthesia • Removal of the LMA • Cleaning, Sterilization and Re-use

  7. Determining Life Span of LMA • intended for 40-50 uses, but highly over-manufactured • tube remains translucent • aperture bars remain intact • cuff deflates correctly • no valve leakage • cuff remains symmetric • pilot balloon retains shape • connector remains tight/ not broken

  8. THE LMA IS NOT DISPOSABLE

  9. LMA and the Difficult Airway • Awake Intubation • Difficult MASK Airway • Blind Intubation • Failed Intubation • Fiberoptic Bronchoscopy and the LMA • Emergent Intubation by an Unskilled Provider

  10. LMA and Pediatric Anesthesia • DL&B • tracheal stenosis • difficult airway

  11. Accuracy of End-tidal CO2 in Pediatrics using LMA 22 children, mechanically ventilated to a stable ETCO2 ventilation via the LMA mean ETCO2 and PaCO2 obtained were 37.7 +/- 3.3 and 41.9 +/- 9.09, respectively ventilation via ETT mean ETCO2 and PaCO2 obtained were 35.2 +/- 2.9 and 39.2 +/- 5.25, respectively LMA ETCO2 is as accurate an indicator of PaCO2 as when ventilated via ETT Anesth Analg Feb;82 (2) :247-50

  12. LMA and OB Anesthesia Questionnaire to 250 anesthesiologists in the UK LMA was available in 91.4% of obstetric units 72% were in favor of using LMA for failed intubation with inadequate ventilation via face mask 24 had experience with LMA in such a situation, 8 of which stated that LMA had proved to be a “lifesaver” Authors believed that we should use LMA before cricothyroidotomy for failed intubation/ventilation Can J Anaesth Gataure, et al. 1995 Feb;42(2):130-3

  13. Advantages of Using the LMA Meta-analysis comparing advantages of the LMA over the tracheal tube or face mask Reviewed 858 LMA publications identified to December 1994, of which 52 met criteria for analysis 32 different issues were tested Can J Anaesth Brimacombe 1995 Nov;42(11):1017-23

  14. Advantages of LMA over ETT • increased speed and ease of placement by inexperienced personnel • increased speed of placement by anesthetists • improved hemodynamic stability at induction and during emergence • minimal increase in intraocular pressure following insertion Can J Anaesth Brimacombe 1995 Nov;42(11):1017-23

  15. Advantages of LMA over ETT • reduced anesthetic requirements for airway tolerance • lower frequency of coughing during emergence • improved oxygen saturation during emergence • lower incidence of sore throats in adults Can J Anaesth Brimacombe 1995 Nov;42(11):1017-23

  16. Advantages of LMA over Face Mask • easier placement by inexperienced personnel • improved oxygen saturation • less hand fatigue • improved operating conditions during minor pediatric otological surgery Can J Anaesth Brimacombe 1995 Nov;42(11):1017-23

  17. Additional Advantages of Using the LMA • leaves provider’s hands free • patient can produce effective cough • allows spontaneous ventilation • even malpositioned can adequately ventilate

  18. Disadvantages of LMA over the ETT • lower seal pressure • higher frequency of gastric insufflation Can J Anaesth Brimacombe 1995 Nov;42(11):1017-23

  19. Disadvantages of LMA over the FM • esophageal reflux more likely Can J Anaesth Brimacombe 1995 Nov;42(11):1017-23

  20. Full Stomach Non-fasted 34+ week pregnant trauma acute abdomen thoracic injury opiate premedication autonomic neuropathy patient unable to follow instructions any condition known to delay gastric emptying Contraindications to Using the LMA

  21. Contraindications to Using the LMA • Full Stomach • Patients with a history of GE reflux

  22. Contraindications to Using the LMA • Full Stomach • Patients with a history of GE reflux • Patients with low pulmonary compliance needing positive pressure ventilation

  23. Complications Arising from Use of the LMA • Aspiration

  24. Passive Regurgitation and the LMA Study looked at gastric regurgitation during GA in different positions with the LMA 15 minutes before induction, patients swallowed a 75 mg methylene blue capsule. supine, Trendelenburg and lithotomy positions post-op, LMA and oropharynx were inspected for bluish discoloration No blue dye was detected in the supine group but it was observed in one patient in each of the other two groups Anaesthesia Strong, et al. 1995 Dec;50(12):1053-5

  25. Passive Regurgitation: LMA v. ETT Study at UT Dallas comparing incidence of reflux for spontaneously breathing anesthetized patients with either an ETT or LMA by continuous measurement of hypopharyngeal pH “Continuous monitoring...failed to detect evidence of pharyngeal regurgitation.” Anesth Anal Joshi, et al. 1996 Feb;82(2):254-7

  26. Complications Arising from Use of the LMA • Aspiration • Coughing

  27. Complications Incidence of airway complications following GA using either ETT or LMA Significantly greater incidence of coughing PRIOR to extubation, AT extubation and AFTER extubation in the ETT group than in the LMA group No airway complications were seen in either group JR Soc Med Denny, et al. 1993 Sep;86(9):521-2

  28. Complications Arising from Use of the LMA • Aspiration • Coughing • Sore Throat

  29. Sore Throat incidence of sore throat looked at in 327 patients who had GA mild/moderate soreness • 7% of patients with LMA • 10% who had FM and oral airway • 47% of had ETT 24 hours later, 3% of intubated group still c/o severe soreness, while NONE of the other patients had any c/o

  30. Other Uses for the LMA • Bronchoscopy • “Big MAC” • Oral Surgery • Head and Neck Surgery • Professional Singers • Laparoscopic Surgery?

  31. Conclusions • Many advantages over ETT and FM • Useful in many areas of anesthesia care • Especially useful in outpatient anesthesia • Safe when used appropriately

  32. Take Home Message • routinely test the cuff before use • avoid lubricating the anterior surface of the mask • only insert the LMA when an adequate depth of anesthesia has been obtained • maintain an adequate anesthetic depth throughout surgery • avoid disturbing the patient during emergence • keep the cuff inflated until the patient is awake

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