Best Practices for LMAs
Review the proper care and use of this essential supraglottic airway device.
Arup De, MD, MBA; and Dino Kattato, CRNA, MS
Fewer sore throats in recovery, improved oxygenation, spontaneous ventilation and better management of difficult airways — the laryngeal mask airway has revolutionized anesthesia care since its introduction in the late '80s. The device's basic design has evolved from a hands-free way to ventilate an anesthetized patient without endotracheal tube intubation to a life-saving device available in many unique configurations. Let's explore best practices for using and caring for this airway management staple.
When originally developed, the LMA was a heat-sterilizable, reusable device made of silicone. Today, single-use devices are also available, which most clinicians prefer, citing concerns of device breakdown over time and the possibility of patient cross-contamination with reuse.
The original LMA, and devices like it, are currently known as "classic" models. They provide low-pressure seals around the glottic aperture to facilitate oxygenation and ventilation. In patients with known difficult airways, intubating LMAs provide an easy-to-use system designed to intubate the trachea with an endotracheal tube advanced through the LMA's ventilation channel. This can be done blindly or with videoscopic assistance on some models.
Some LMAs have been developed with separate channels through which an orogastric tube can be advanced into the stomach for decompression of acid or air. Flexible LMAs provide ventilation lumens that are wire-reinforced, which increase the flexibility of the tube without disrupting the seal at the glottis. These devices are often used in eye or ENT procedures, because the ventilation channel can be manipulated out of the surgical field without compromising ventilation. Some LMAs also have integrated bite blocks, which prevent occlusion of the ventilation channel by reflexive masseter spasm during emergence.
There are many clinical benefits associated with LMA use. In procedures requiring general anesthesia without muscle paralysis, the LMA is an outstanding tool that allows spontaneous ventilation. It provides the benefits of mask ventilation without such drawbacks as leaks or poor mask seals. In patients with known or unanticipated difficult airways, it can be used as a rescue device to provide ventilation and oxygenation. It has become the go-to device in scenarios where intubation is not possible and mask ventilation is challenging.
The LMA also provides a conduit for intubation, because the opening of the device usually rests directly above the vocal cords and glottis. In patients with poor dentition, the LMA allows placement of a secure airway without requiring the use of a laryngoscope, potentially limiting iatrogenic periodontal trauma.
LMAs can be used in almost all types of surgical procedures requiring general anesthesia and across all age groups. The LMA has become a critical piece of the American Society of Anesthesiologists' difficult airway algorithm. The ASA recommends LMAs when initial attempts at intubation have failed and mask ventilation is inadequate.
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