23

Laryngeal Mask Airway

Brian Egan, MD Reuben L. Eng, MD
The laryngeal mask airway (LMA) is a supraglottic airway device that sits
above the glottic opening to facilitate ventilation of patients under general
anesthesia. The device is placed blindly into the airway and seals the
laryngeal inlet to allow easy ventilation of the patient.
1. Overview
a. The LMA is a supraglottic airway device that consists of a tube connected to
an inflatable cuff; this cuff is inserted into the pharynx to permit ventilation
of a patient under general anesthesia.
b. It was invented by British anesthesiologist Archie Brain and introduced to
clinical practice in Britain in 1983 and the United States in 1991.
c. Today, the LMA remains one of the most commonly used supraglottic airway
devices.
d. Function of the LMA
i. The LMA cuffed mask seals off the laryngeal inlet from the gastrointestinal
inlet (Fig. 23-1).Figure 23-1 Dorsal View of the LMATM Cuff Showing
Position in Relation to Pharyngeal
ii. The tip of the mask sits in the hypopharynx, at the level of the upper
esophageal sphincter (UES), with the lateral aspects of the mask spreading
into the pharynx, and the superior component displacing the base of the
tongue forward.
iii. The glottic opening and epiglottis sit within the bowl formed by this
chamber; spontaneous ventilation (SV) or positive pressure ventilation (PPV)
is effectively channeled via the bowl and into the respiratory tract (
1
).
2. Advantages of LMAs
a. A supraglottic airway offers several advantages over an endotracheal tube
(ETT) or mask ventilation, including
i. Minimal hemodynamic changes with placement due to decreased stimulation
with LMA placement
ii. Low risk of dental/perioral trauma
iii. First-pass success rates of up to 89%, and successful use in up to 98% of
patients appropriately selected for LMA use (
2
)
iv. Minimal airway reactivity upon placement, assuming appropriate anesthetic
depth
v. Low incidence of postoperative sore throat
vi. Compared to a mask general anesthetic, the LMA frees the anesthesiologists
hands from having to hold a mask
vii. Minimizes coughing/pharyngeal irritation on emergence
viii. Avoids tracheal intubation in special patient populations (e.g., singers)
3. Disadvantages of LMAs
a. PPV is limited to peak airway pressures of 20 cm H2O with the Classic LMA,
and 30 cm H
2
O with the ProSeal and Supreme LMAs.
i. This limitation is due to the fact that the pressure at the lower esophageal
sphincter (LES) is approximately 20 cm H
2
O.
ii. Ventilation with airway pressures >20 cm H
2
O carries the risk of gastric
insufflation.

Patients at high risk of aspiration may not be good candidates
for LMA.
b. Although the aspiration risk is reported as <0.02% (
3
), the airway is not
completely protected from aspiration of gastric contents.
i. Patients at high risk of aspiration (e.g., obese, pregnant, gastroesophageal
reflux disease, full stomach) may not be good candidates for LMA.
c. Adequate function of the LMA is dependent onappropriate position in the
hypopharynx.
i. It is susceptible to displacement with changes in patient position and/or
manipulation of the head and neck.
d. Reported rare, but severe, neurovascular complications due to trauma
secondary to LMA use include
i. Lingual nerve injury (
4
)
ii. Recurrent laryngeal nerve injury (
5
)
iii. Hypoglossal nerve injury (
6
)
iv. Tongue cyanosis (
7
)
4. Description of different types of LMAs
a. Classic LMA and Unique LMA
The LMA can be used as a rescue airway device for situations
where difficult intubation and/or ventilation occur.
i. The Classic
1. The original LMA
2. Reusable for 40 uses
ii. The Unique
1. The disposable version of the Classic
iii. All versions are latex-free.
iv. Designed for SV, though PPV to a maximum of 20 cm H
2
O has been safely
utilized without any sequelae of gastric insufflation
v. Can be used as a rescue airway device for difficult intubation/ventilation
scenarios (
8
)
b. ProSeal LMA
i. The cuff of the ProSeal rests deeper in the hypopharynx, thus improving the
seal and permitting PPV up to 30 cm H
2
O.
ii. A gastric drainage conduit was added to allow contents of the gastrointestinal
tract to be safely suctioned, bypassing the mouth and respiratory tract.
1. A 14-French orogastric tube can be placed through the drainage tube to
decompress the stomach.
c. Flexible LMA
i. Designed to optimize LMA use in shared airway cases in which surgeons
operate in close proximity to the airway
1. The Flexible LMA can be easily positioned out of the surgeons working
space.
ii. Wire-reinforced, flexible breathing tube
1. Allows maintenance of proper mask position in the hypopharynx while the
tube isproximally displaced at extreme angles.
iii. The tube is longer and of smaller diameter.
1. Increases resistance to air flow through the LMA.
d. Supreme LMA
i. Like the ProSeal, a drain tube terminates in the tip of the mask and should
sit in the UES.
ii. Has a built-in bite block, a more rigid breathing tube facilitates non-digital
placement, and a fixation-tab and dual tube configuration that minimizes
rotational displacement.
e. Intubating LMA and LMA C-trach
i. Designed to facilitate tracheal intubation
ii. The basic components of the Classic LMA are retained but modified to
achieve both blind and videoscope-guided placement of an ETT.
iii. After successful ETT placement, they are typically removed from the airway.
1. However, they can remain in situ when conditions make removal prohibitive.
5. Placement of an LMAStandard technique
a. Preparation of the LMA
Read More
Atlas of anesthesia procedures: Laryngeal mask airway
insertion,Chapter 153, page 1099
i. Completely deflate the cuff of the mask with a syringe into a flat, smooth,
wedge-shaped tip to minimize down-folding of the epiglottis on placement.
ii. Place water-soluble lubricant on the posterior surface of the cuff only.
1. Placement on the ventral surface could cause airway obstruction and
aspiration of lubricant, as well as laryngospasm secondary to vocal cord
irritation by lubricant.
2. Lubricant should be placed right before LMA insertion to minimize drying.
b. Patient positioning
i. LMA placement is facilitated by neck flexion and head extension (i.e., the
sniffing position).
1. Grasp and push the head with the nondominant hand during insertion to place
the patients head in the sniffing position.
c. Insertion (Fig. 23-2) (
9
)
i. LMA Classic, Unique, and Flexible
1. Grasp the tube in the dominant hand, and place the index finger in the space
between the tube and the deflated cuff of the mask.
2. Use the nondominant hand to place the patients head in the sniffing
position.
3. With the flat side of the cuff facing the patients head, place the tip of the
mask firmly against the hard palate and advance the LMA along the palate,
above the tongue, and into the posterior pharynx in a smooth continuous
motion; the initial direction of force should be directed toward the operators
umbilicus.
4. The nondominant hand is then used to push the LMA further into the
hypopharynx until resistance is encountered at the UES; 7 to 10 cm of LMA
should protrude from the oral cavity.
a. Withdraw the index finger while stabilizing the LMA with the opposite hand.
Figure 23-2 Technique for Insertion of LMA Top Left: Grasp the airway
tube in the dominant
d. Completion
i. Inflate the mask with just enough air to create a seal.
1. Maximum inflation volumes (to keep the pressure <60 cm H
2
O) are printed
on each device.
ii. A slight rise (1 to 2 cm) of the LMA out of the mouth on inflation suggests
that the LMA is appropriately positioned.
iii. Connect the circuit, and confirm proper placement by gentle manual
ventilation.
1. Observe for chest rise, presence of ETCO
2
, and listen for an audible leak,
evidence of airway obstruction, and bilateral breath sounds.
e. Troubleshooting
i. Difficulty ventilating through the LMA
1. Possible etiologies:
a. Inadequate anesthetic depth
b. Epiglottis has folded over during insertion, thus obstructing the airway
c. Tip has migrated into the airway rather than the esophageal inlet, thus
malpositioning the LMA
ii. With correct placement, an ovoid swelling in the anterior of the neck is often
visible.
iii. When in doubt, take it out, ensure adequate depth, and reinsert.
f. Ventilation
When in doubt of LMA proper positioning, take it out, ensure
adequate depth, and reinsert.
i. Spontaneous ventilation is preferred for the Classic LMA and Unique LMA.
1. Well tolerated when anesthetic depth is appropriate for the level of
stimulation.
2. Changes in respiratory pattern (e.g., sudden increase in tidal volume or
respiratory rate) suggest inadequate depth of anesthesia.
3. Positive pressure ventilation can be done safely, with some caveats.
a. To avoid gastric insufflation, keep peak airway pressures <20 cm
H2O (Classic, Unique, Flexible) or <30 cm H
2
O (ProSeal, Supreme); this is
because the pressure at the LES is approximately 20 cm H
2
O.
b. Pressure-control ventilation may help to avoid excessive peak pressures.
g. Emergence and removal of LMA
i. Ensure the patient is breathing spontaneously and not requiring ventilatory
support.
ii. No need to suction the airway because the cuff provides adequate protection
from secretions.
1. Suctioning may trigger airway reactivity or laryngospasm if the patient is
lightly anesthetized.
iii. Leave the cuff inflated on removal.
1. Prevents pooled secretions on the posterior surface of the cuff from falling
into the airway.
iv. The LMA can be removed either when the patient is deeply anesthetized or
when the patient is fully awake.
1. Awake removal of LMA
a. Do not disturb the patient until swallowing is observed. This facilitates a
smooth emergence.
b. Remove the LMA only when the patient can open his or her mouth on
command.
2. Deep removal of LMA
a. If the patient is inadequately anesthetized, there is a risk of laryngospasm;
vigilancemust be used when monitoring for this complication throughout the
emergence phase.
b. After confirming a deep plane of anesthesia (e.g., assess for central gaze of
eyes, dilated pupils [assuming no other factors affect pupillary size]), remove
the LMA from the oral cavity.
c. Consider 100% oxygen for a brief period before removing LMA to optimize
apneic time in the event of transient upper airway obstruction after LMA
removal.
d. Consider placing the patient in a lateral decubitus position after removal of
LMA to facilitate outward drainage of oral secretions.
h. Complications associated with LMA use
i. Aspiration
1. Regurgitation of gastric contents occurs rarely, and aspiration of gastric
contents even more rarely, in part because of LMA design and appropriate
patient selection for LMA use.
2. If regurgitation does occur, place the patient in the head-down
(Trendelenburg) position.
a. This encourages gastric contents to flow out the mouth.
3. Leave the LMA in place.
4. Suction down the airway tube with a soft suction catheter.
a. If secretions are aspirated from the airway, consider suctioning via fiberoptic
scope or replacing the LMA with an ETT.
ii. Cuff trauma
1. The cuff of the LMA can place traumatic pressure on vulnerable anatomic
structures,including the
a. Mucosa
b. Hypoglossal nerve
c. Lingual and superior laryngeal nerves
2. Avoiding cuff trauma
a. Use the minimal amount of air to create a good seal.
i. Do not exceed the recommended maximum cuff volumes.
ii. Additional air rarely improves a poorly ventilating LMA.
1. It is better to remove and replace the LMA.
b. Avoid any tension on the airway tube (e.g., via the anesthetic circuit) because
it may be translated distally to the cuff, and thus to the tissues against which
the cuff approximates.
iii. Laryngeal injuries
1. There are rare cases of arytenoid cartilage dislodgement, vocal cord injury,
and/or paralysis.
2. Proper placement of the LMA obviates direct contact with glottic structures.
3. The period of greatest resistance to LMA advancement occurs when the tip
slides behind the tongue.
a. Typically, there is a notable decrease in resistance once this is achieved.
b. Persistent resistance to advancement should be treated with caution.
i. Removing the LMA to the level of the palate and readvancing is advised.
iv. Other uses
1. Airway emergencies
a. The LMA Classic, Unique, ProSeal, and Supreme are part of the ASA
difficult airway algorithm.
i. May be used in situations of difficult mask ventilation and/or intubation (
8
).
ii. Depending on the clinical scenario, the availability and use of a rescue airway
with gastric decompression capability may be favored.
b. Fiberoptic conduit
i. The exit point of the LMA airway tube through which the fiberoptic scope
emerges from the LMA permits good visualization of the glottic opening or
epiglottis.
1. This allows examination of vocal cord function during certain surgeries
(e.g., thyroid procedures).
2. Also provides a conduit for fiberoptic intubation.
ii. Modifications of the disposable Unique have been suggested to facilitate
fiberoptic intubation.
1. Removing the airway bars at the distal end of the airway tube (
5
,
6
,
7
,
8
,
9
) and
shortening the tube to ensure complete passage of the ETT balloon after rail-
roading.
2. Use of an Aintree Intubating Catheter can also facilitate fiberoptic intubation
through an LMA (
10
).
Chapter Summary for Laryngeal Mask Airway

References
1. http://www.lmana.com/docs/LMA_Airways_Manual.pdf. Accessed June
2009.
2. Wakeling HG, Butler PJ, Baxter PJ. The laryngeal mask airway: a
comparison between two insertion techniques. Anesth Analg 1997;85:687
690.
3. Brimacombe JR, Berry A. The incidence of aspiration associated with the
laryngeal mask airway: a meta-analysis of published literature. J Clin
Anesth 1995;7:297305.
4. Foley E, McDermott TED, Shanahan E, et al. Transient isolated lingual nerve
neuropraxia associated with general anesthesia and laryngeal mask use: two
case reports and a review of the literature. Ir J Med Sci 2010;179:297300.
5. Endo K, Okabe Y, Maruyama Y, et al. Bilateral vocal cord paralysis caused
by laryngeal mask airway. Am J Otolaryngol 2007;28:126129.
5. Ianchulev SA. Letter to the editor. Anesth Analg 2005;101:18821883.
6. Stewart A, Lindsay WA. Bilateral hypoglossal nerve injury following the use
of the laryngeal mask airway. Anaesthesia 2002;57:264265.
7. Wynn JM, Jones KL. Tongue cyanosis after laryngeal mask
insertion. Anesthesiology 1994;80:14031404.
8. www.asahq.org/publicationsAndServices/Difficult%20Airway.pdf. Accessed
June 2009.
9. Walls RM, Murphy MF. Manual of Emergency Airway Management. 3rd ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2008:125127.
10. Blair EJ, Mihai R, Cook TM. Tracheal intubation via the classic and
proseal laryngeal mask airways: a manikin study using the Aintree Intubating
Catheter. Anaesthesia 2007;62:385387.