SUPRA

GLOTTIC
AIRWAY
DEVICES
DR. VINOD
KUMAR

INTRODUCTION

Devices that are used to maintain the airway patency and provide
ventilation by placing just above the glottic opening.

They sit outside the trachea and provide a hands free means of
gas tight airway.

Standard of airway management , filling the niche between

facemask and tracheal tubes.

Dr. Archie Brain developed LMA in 1982 as a modification of

Goldman dental mask with ET tube.

The first commercially available supraglottic airway device was

LMA-Classic(1988).

CLASSIFICATION

Based on Generation:LMA
First Generation
Simple airway device.
Low pressure
pharyngeal seal
May or may not protect
from aspiration.
Have no specific design
to lessen the risk.
Eg.cLMA
Flexible LMA
All LMs
Laryngeal tube
Cobra perilaryngeal
airway

Second Generation
Specially designed for
safety.
High pressure pharyngeal
seal.
Reduce the risk of
aspiration.
May be more efficacious
in ventilation.
Eg.PLMA,
Supreme LMA,
Laryngeal tube suction
2,
Laryngeal tube suction

INDICATION

Alternative airway during GA specially in short surgical

procedures and minor therapeutic or diagnostic procedures
like radiation therapy, diagnostic and interventional
radiology, endoscopy, ECT etc.

Cardiopulmonary resuscitation to secure the airway.

Essential part of difficult airway trolley.

Primary airway device when urgent airway patency is

required in lateral position as lesser time required to place
LMA in the lateral position as against endotracheal
intubation in this position.

Relative indication- in professional singers to avoid vocal

cord trauma.

CONTRAINDICATION

Limited mouth opening (< 2 fingers)

Local pathology in pharynx , larynx or upper airway.

Trismus, facial or upper airway trauma

Increase risk of aspiration- Morbid obese, > 14 week

pregnant,

prior opiods medication, delayed gastric empting, acute

abdominal or thoracic injury, history of GERD, and hiatus
hernia.

Reduced lung compliance/increase work of breathing

ADVANTAGES

Increased speed and ease of

placement.

Less requirement of expertise.

Improved hemodynamic stability at

induction and during emergence of
anesthesia.

Minimal IOP and ICP changes during

insertion.

DISADVANTAGE
Inadequate positive
pressure ventilation.
More chances of aspiration
of gastric content.
Sore throat.

Increase airway tolerance.

Lower frequency of coughing during Vascular compression and

nerve damage.
emergence.

Improved oxygen saturation during

emergence

LMA- Classic
Comprised

of three main
components
Airway

Tube

Mask
Inflation

line

Mask

designed to conform to the

contours of the hypopharynx with
its lumen facing the laryngeal
opening.

Made

of medical grade silicone, it

can be autoclaved and reused
many times.

Seal

pressure =25cmH2O

SIZE SELECTION
Mask Size

Patient size /Body Weight

Maximum Cuf
Inflation Volume
(Air)

Neonates/Infants up to 5 kg

Up to 4 mL

1.5

Infants 510 kg

Up to 7 mL

Infants/Children 1020 kg

Up to 10 mL

2.5

Children 2030 kg

Up to 14 mL

Children 3050 kg

Up to 20 mL

Adults 5070 kg

Up to 30 mL

Adults 70100 kg

Up to 40 mL

Large Adults over 100 kg

Up to 50 mL

PREPARATION PRIOR
TO INSERTION

Select the proper size of LMA.

Inspect the LMA for any tear , blockage .

Slowly deflate the cuff to form a smooth flat wedge shape .

Over inflate: look for leak.

Use a water soluble lubricant to lubricate the posterior surface

of LMA just prior to insertion.

Avoid excessive amounts of lubricant

-on the anterior surface of the cuff or
-in the bowl of the mask.
Avoid lignocaine jelly for lubrication .

INSERTION
TECHNIQUE
Position: Neck flexed and head extended.

Use non-inserting hand to stabilize occiput.

Jaw should be pulled down by assistant.

LMA tube be grasped like a pen with index

finger pressing the point where tube joins
mask.

Place the tip of the LMA against the inner

surface of the patients upper teeth.

Aperture facing forward, the tip pressed

upwards against the hard palate.

Mask is advanced into pharynx to ensure

that tip remains flattened and avoids the
tongue.

Continue..

Neck is kept flexed and head extended.

Press the mask into the posterior

pharyngeal wall using the index finger.

Continue pushing with your index finger

and guide the mask downward into
position.

Grasp the tube firmly with the other hand

and then withdraw your index finger from
the pharynx.

Press gently downward with your other

hand to ensure the mask is fully inserted.

Continue..

Inflate the mask with the

recommended volume of air.

Do not over-inflate the LMA.

Normally the mask should be

allowed to rise up slightly out of
the hypo pharynx as it is inflated
to find its correct position.

Insert a bite-block or roll of gauze

to prevent occlusion of the tube.

Now the LMA can be secured

utilizing the same techniques as
those employed in the securing of
an endotracheal tube.

OTHER METHODS OF
INSERTION

1. Thumb index method.

2.Partial inflation method.

3.180 degree rotation method.

4.Laryngoscopy aided method.

5.Stylet aided method.

6.Insertion from the side of the mouth opening.

SIGNS OF CORRECT
PLACEMENT

The slight outward movement of the

tube upon LMA inflation.

The presence of a smooth oval

swelling in the neck around the
thyroid and cricoid area, or no cuff
visible in oral cavity.

Ventilate the patient while confirming

equal breath sounds over both lungs
in all fields and the absence of
ventilatory sounds over the
epigastrium.
Part of LMA

Position

Distal tip of silicone

cuff

Upper esophageal
sphinter

Sides of the cuff

Pyriform fossa

Upper part of the

cuff

Tounge base

PROBLEMS

Failure to press the deflated mask up

against the hard palate or inadequate
lubrication or deflation can cause the
mask tip to fold back on itself.

Once the mask tip has started to fold

over, this may progress, pushing the
epiglottis into its down-folded position
causing mechanical obstruction .

If the mask tip is deflated forward it can

push down the epiglottis causing
obstruction

If the mask is inadequately deflated it

may either

push down the epiglottis

enter the glottis.

INTUBATION WITH C1.Blind intubation. LMA

2.Fibrescope guided.

3.retrograde.

4.Lighted stylet guided.

5.Nasotracheal intubation.

DISADVANTAGES:1.Standard tube not long enough to insert.

2.Pilot tube may kincked.
3.Cricoid pressure make it difficult to pass the tube.
4.Paediatric-largest uncuffed tube too small to allow good seal for PPV.
5.Removal of the LMA disturbs the ET tube
6. PPV not always possible due to moderate pharyngeal seal.
7.More risk of aspiration

Steps to reduce the

chance of aspiration
Action after aspiration

Avoid in patients who are un-fasted,

or have factors predispose to
1. Do not attempt to remove
regurgitation.
LMA.
2. Disconnect the circuit and
Routinely test the cuff for defects
allow to drain the fluid
before use.
while head is down & to the
Avoid lubricating the anterior
side.
surface of the mask, since the
3. Suction the LMA & give
lubricant may be aspirated.
100% O2.
Insert the LMA only when adequate 4. Ventilate manually with low
gas flow & small TV.
depth of anesthesia has been
5. Evaluate tracheobronchial
reached.
tree & suction the
Avoid disturbing the patient during
remaining fluid with FOB.
emergence from anesthesia.
6. Intubate when aspiration
below vocal cords.
Keep the cuff inflated till the patient

LMA - UNIQUE

Single use , PVC made ,

cheaper.

Tube stiffer , Cuff- less

compliant.

Less rise of intracuff presuure

with N2O.

More difficult to insert.

Size same as cLMA.

FLEXIBLE LMA

Flexometallic tube- narrower & longer.

Has a rigid preformed angle at the cuff.

Seal pressure=20cmH2O

More difficult to insert.

Introducer helps to stabilize the airway

tube during insertion & it is removed once
mask is in place.

It has a less incidence of dislodgement

once placed.

More useful in head & neck surgeries, ENT

and upper torso procedures where need to
reposition the airway is prevalent

Problems- Disruption of spiral reinforce

wire, Increased airway resistance , limits
endoscope & tracheal tube passage ,
unsuitable for MRI.

SOFT SEAL LARYNGEAL

MASK

similar to the single-use LMA.

The ventilation orifice is wider and it is
characterized by the absence of mask
aperture bars.
Cuff is more elliptical.

insertion with the cuff partially inflated

is recommended.

A maximum intracuff pressure of 60 cm

H2O is recommended.

may be used as an intubation conduit.

The large bowl of the device and its PVC

Construction inhibit easy insertion.

INTUBATING LARYNGEAL
AIRWAY

medical-grade silicon and latex free.

airway tube is curved similar to the

anatomical curve of the upper airway
to eliminate the need to bend the tube
further during use, which can lead to
kinking.

Mask- keyhole outlet to direct ETT to

laryngeal inlet.

3 ridges on inflation of mask, these

ridges move against the posterior
pharynx and improve anterior mask
seal.

After intubation , ILA can be removed

without dislodging the ETT using a
reusable "ILA Removal Stylet.

Low airway seal, high risk of aspiration.

INTUBATING LMA

A modification of the c-LMA.

A rigid (stainless steel) anatomically

curved,short & wide bored shaft that
follows the anatomical curve of the palate
and the post pharyngeal wall.

An epiglottic elevator bar at the mask

aperture

Armoured flexible ET tube with a

longitudinal and a horizontal black linecoincides with the epiglottic elevating
bar.

The Stabilizer Rod of 25cm.

Seal pressure=60cmof H2O max.

Body
weight

ILMA
size

Air
volume

Tracheal
Tube

30-50kg

20ml

7mm

50-70kg

30ml

7.5mm

70-100kg 5

40ml

8mm

INSERTION

Position: Neutral

Hold rigid handle parallel to patients chest.

Glide the mask along the palate till the straight part of the rigid
tube is parallel to the chin.

Rotate the rigid handle directing towards patients nose till it can
not be advanced.

Inflate the cuff & check ventilation.

Introduce FETT with black line faceing rigid handle till 15 cm mark.

Now grip ILMA handle firmly and lift it forward by few mms without
levering.

Advance the tube using clinical judgment.

Inflate the cuff and check for tracheal intubation.

Continue..

After confirmation of tracheal intubation deflate the ILMA cuff.

Remove FETT connector

Insert the stabilizing rod in the FETT to keep it in place.

Remove the ILMA gently over the stabilizing rod until it is clear of
the oral cavity.

Stablize the FETT to prevent accidental extubation.

Remove ILMA and the stabilizing rod.

Reconnect FETT connector and the breathing circuit and

confirm position again

CHANDYS MANEUVER

They increases the seal pressure and aligns the axes of trachea
and FETT.

First step : Rotating ILMA in coronal & sagittal plane in an attempt

to find least resistant ventilation position.

Second step : is to grasp the handle and use it to draw LMA

forward 2-5 mm in a lifting action without levering teeth.

ADVANTAGES

DISADVANTAGES

Useful in cant intubate, cant More likely to dislodge in head or

neck manipulation.
ventilate scenarios.

Unsuitable for MRI.

Allows fast insertion into

correct position without
Difficulty in insertion with limited
moving patients head or neck. mouth opening.
On removal of ILMA , tracheal tube

Can be used alone or as a

can be displaced downwards.
guide to intubation.
Facilitates ventilation between
ILMA insertion and ETT
insertion
Good conduit for fibreoptic
intubation in presence of blood
or clot in oral cavity.
Difficult laryngoscopic view is
irrelevent to the success of
ILMA intubation.

PROSEAL LMA

Reusable , silicon made , most

specialized modification of cLMA.

Modifications:-

(i) oesophageal drain tube

(ii) posterior inflatable cuff
(iii) reinforced airway tube
(iv) integral bite block
(v) introducer
Higher leak pressure(35cm of H2O)
than c-LMA(25cm of H2O).
Size- in 7 sizes (1-5) like the C-LMA
with drainage tube of
8,10,10,14,16,16&18 Fr respectively.

INSERTION

(i) Standard: identical to the cLMA, but

demanding careful attention to detail.

(ii) Introducer: a metal introducer is attached

to the concave side of the device. It is then
introduced in the same manner as an
intubating LMA.

(iii) Bougie-guided: a bougie is placed upside

down into the oesophagus and the PLMA is
railroaded into place via the drain tube
(suction catheters or orogastric tubes are
alternatives).This technique had a
significantly higher success rate.

Positioning:- The easy passage of an

orogastric tube into the stomach via the
oesophageal tube has been shown to
correlate with optimal anatomical airway
positioning over the larynx.

ADVANTAGES

Increased airway seal improves the PPV.

Decreased chance of aspiration1.Oesophageal opening is isolated from the airway.

2.Drain tube vents gas leaked into the oesophagus.
3.On regurgitation drain tube vents the fluid & small solid
particles beyond the pharynx.
4. The large bulk of the PLMA reduces the space available for
regurgitated fluid to pool.
5. Increased oesophageal and pharyngeal seal decreases the risk
of any pooled fluid entering the laryngeal inlet.

Simple tests enable correct positioning of the PLMA to be

confirmed.

The stomach may be accessed with an orogastric tube.

DISADVANTAGES

1. Less suitable as an intubating device as an ILMA b/c narrow

airway tube.

2.Slightly longer time required to insert than C-LMA.

3.Can cause airway obstruction by- compression of supraglottic

structure or cuff in folding.

4.Contraindicated for intraoral surgery .

LMA - SUPREME

Single use, PVC made 2nd generation

LMA.

Has features of P-LMA, I-LMA & LMA

unique.
(i) Single use , PVC- (cf.LMA unique).
(ii) Large inflatable plastic cuff, but
no posterior cuff (cf. PLMA)
(iii) Oesophageal drain tube
(iv) Preformed semi-rigid tube
(v) Fins in the mask bowl to prevent
epiglottic obstruction(cf. PLMA,
cLMA)

Pharyngeal seal is intermediate

between cLMA and PLMA( 2630 cm
H2O)

Oesophageal seal not reported.

ADVANTAGES

DISADVANTAGES

The reinforced tip reduces the

risk of fold-over, compared with
drain tube runs through the
the PLMA.
middle of the airway tube (rather
Anatomic curve that facilitates
than next to it in the PLMA)
easy insertion.
dividing it into two narrow
lumens. This limits its use for
A drain tube to allow gastric
airway inspection
aspiration.
and for use as a conduit for
A high volume/ low pressure
intubation.
cuff which generates higher
seal pressure (36.1 vs 27.4cm
Being made of PVC, the SLMA
H20 of LMA unique).
may cause more trauma than
A built-in bite block and
silicone devices
fixation tab to help secure the
airway

4- An oval airway cross section

for improved stability of the
airway

LMA C-Trach

Enables combined ventilation,

visualization, and intubation.

High first attempt intubation success

rate of 91%.

Fiberoptic technology allows real time

visualization of the glottic opening and
of the ET tube passing through the
vocal cords.

Ideal in rescue/difficult airway

situations .

Completely portable and wireless

system weighs less than eight ounces.

Easy to learn and very effective

INSERTION

Inserted exactly the same as the LMA Fastrach.

Once the airway is secured and patient is being ventilated

The viewer is switched on, placed in the magnetic connector and a

clear image of the larynx is displayed in real time.

The ET tube can be viewed as it enters the trachea. Once the

patient is intubated, the viewer is removed and the mask is
removed leaving the ET tube in place.

Problems:1. It has a poorer image quality than a flexible fiberoptic

endoscope.
2. It cannot be used easily in the patient with a limited mouth
opening.
3. The view may be obstructed by secretions, lubricant, or blood.

i-GEL

Novel SAD designed by UK anaesthetist,

Muhammed Nasir.

(i) Single use.

(ii) Cuffless: the mask is made of a soft

polymer and is shaped similarly to an
inflated LMA posteriorly with its anterior
shape designed to fit the perilaryngeal
structures.

(iii) Narrow-bore oesophageal drain tube.

(iv) Short, wide-bore airway tube.

(v) Integral bite block

(vi) Contains an epiglottic rest at the

anterior part of the cuff which reduces
the possibility of epiglottis down folding
and airway obstruction.

Continue

Mask is made of a thermoplastic elastomer (SEBS-Styrene Ethylene

Butadiene Styrene) that has the flexibility and feel of human
tissue. . After placement, body heat from the patient activatesthe
gel component of this airway whichexpands to fill the void in the
hypopharynx where the device rests.
Advantages:-

1. easy to insert: due to a combination of a very,very low

coefficient of friction when lubricated & absence of cuff.

2. truncated tip, with the aim of reducing post-use dysphagia.

3. wide lumen make it well worth for both airway rescue and as a
conduit for assisted intubation.

4. A gastric channel allows for suctioning and placement of a

nasogastric tube.

5.Though oesophageal seal is low but enough (according to the

manufacturer).

LARYNGEAL TUBE
multiuse, latex-free, singlelumen silicon tube
two low pressure cuffs
(proximal and distal).

The distal balloon

(esophageal balloon) seals
the airway distally

The proximal balloon

(oropharyngeal balloon) seals
both the oral and nasal
cavity.
Two anterior ,oval ventilating
vents between the cuffs.
Cough pressure 60cmH2O

4 types- LT, LT-D, LTS-II, LTs-D

INSERTION

Open the mouth app. 3 cm using the

thumb and index finger technique in
neutral position of head.

Hold like a pen in the area of the

teeth marks (three black marks).

Insert centrally along the hard palate

into the hypopharynx.

Advance until a slight resistance is

felt. The center black line should n be
level with the upper front teeth.

Inflate the cuffs considering the

respective colour code.

Connect bag to the 15 mm standard

connector.

place the tube deeper, inflate the

cuffs and withdraw until ventilation is
optimized results in the best depth of
insertion because tissue is retracted
away from the laryngeal inlet.

SIZE

VOLUME(ml)

10

20

35

2.5

45

60

80

90

ADVANTAGES
1.

Easy insertion.

2.

2.High ventilation pressure

can be used.

3.
4.

Better protection from

aspiration.
Can be used to intubate the
trachea.

DISADVANTAGES
1.Airway obstruction.
2.Displacement on head &
neck movement.
3. Cuff rupture
4. Trauma to pharynx.

ESOPAHGEAL- TRACHEAL
COMBITUBE

PVC double lumen supraglottic

airway device with two inflatable
balloons
2 Lumens: tracheal and pharyngeal
Ventilation -either tracheal or
esophageal intubation
95% of cases tube enters the
esophagus
Proximal balloon-seals the oral and
the nasal cavity
Distal balloon - seals either the
esophagus or the trachea,
depending on which of these the
ETC has been sited.
Size- 37 Fr for height up to 5 ft.
41 Fr for height above 5.5 ft.
Between 5-5.5ft either of these.

INSERTION

Neutral position. Lift the tongue and lower

jaw upward to open the oropharynx .

Lubricate the tube with sterile, water

soluble lubricant.

Insert the Combitube so that it curves in

the same direction as the natural
curvature of the pharynx .

If resistance is met, withdraw tube and

attempt to reinsert.

Advance tube until the patients teeth are

between the two black lines.

Inflate the blue pilot cuff with 100ml of air

from the large syringe.

Inflate the white pilot cuff with 15ml of air

from the small syringe.

Begin ventilation through the longer tube .

If auscultation of breath sounds is good
and gastric inflation is negative, continue
and vice versa.

INDICATION
1.

2.
3.
4.
5.

Patients in irreversible
respiratory arrest (i.e.
narcotic overdose,
hypoglycemia).
Patients in cardiac arrest.
Ventilation in
normal/abnormal airways
Failed intubation
Unconscious patients
without a gag reflex, and in
need of ventilatory support

CONTRAINDICATION
1. Intact gag reflex
2. Under 4 feet tall & Under
16 years of age
3. Conscious arouseable
patient
4. Known esophageal disease
(cancer, varices)
5. Ingestion of caustic
substances
6. Stoma or functional surgical
airway
7. Partial or complete FBAO
8. CONSIDER: Latex Allergy

ADVANTAGES
1.

Requires minimal training

2.

May be more useful in nonfasted patients

3.

Successful passage and

ventilation in many patients
via esophageal route

4.

Portable, useful in remote

setting

5.

Functions in either the

trachea or esophagus

DISADVANTAGES
1. Only adult and small
adult sizes
2. Potential for esophageal
trauma
3. Problems maintaining
seal in some patients

STREAMLINED LINER OF
THE PHARYNGEAL
Plastic made, uncuffed, disposable ,2
generation SAD. AIRWAY

nd

Anatomically pre-shaped to line the

pharynx.

Hollow & boot shaped distal part-

1.

Toe- rest in the oesophageal entrance.

2.

Bridge- fits to the pyriform fossa.

3.

Heel- anchor in correct position & connect

the airway tube.

4.

Two lateral bulges- relieve pressure on

Hypoglossal& recurrent laryngeal NV.

5.

Large capacity chamber-store regurgited

fluid.

Available in 6 sizes- relate to dimension

across the bridge: 47, 49, 51, 53, 55, and
57 mm.

ADVANTAGES
1.

Easy to insert.

2.

Greater airway sealing pressure.

3.

N2O has no effect on sealing

pressure- as no cuff.

4.

Effective protection against

aspiration during PPV

CONTRAINDICAT
ED
Upper airway
abnormality.

CUFFED
OROPHARYNGEAL
PVC made , single use ,1 generation.
AIRWAY
The distal cuff inflate below the soft
st

palate, behind the tongue, above the

epiglottis, and within the oropharynx.

Available in five sizes: 7, 8, 9, 10, and 11

cm length with cuff inflation volume of 20,
25, 30, 35, and 40 ml respectively.

Insertion like Gudels oropharyngeal

airway.

COPA is recommended for use in

spontaneously breathing patients with no
risk factors for aspiration.

It is quick and easy to place.

Easy size selection & low cost.

Less airway protection

ELISHA AIRWAY
DEVICE
Silicon made , latex
free, latest.
three separate channels for ventilation,
intubation, and gastric tube insertion.
Ventilation channel (VC) and Intubation
channel (IC) are side-by-side but join at
the ventilation outlet situated in front
of the laryngeal inlet.

The VC has a standard 15 mm

connector at th proximal end.

The IC allows passage of an 8.0 mm ET

tube for blind or fiberoptic-guided
intubation.

Gastric tube channel (GTC) has an

outlet located in the distal end of the
device.

Two high-volume, low-pressure cuffs.

Proximal cuff seals the oropharynx and nasopharynx &

distal cuff seals esophagus.

Both are inflated through a single pilot port with 50 cc of air

resulting in an intra-balloon pressure of approximately 70 cm
H2O.

Provide combination of 3 functions in a single device:

ventilation, intubation (blind and/or fiberoptic-aided) without
interruption of ventilation, and gastric tube insertion.

OTHER NEWER SAD

Eldor Laryngeal Airway.

Glottic Aperture Seal Airway.

Glossopalatine Tube. Etc.

EFFICACY VS SAFETY

For the evaluation of efficacy (absolute & relative ) small clinical

trials can be used.

Contrary, evaluations of safety (like ventilation failure rates ,

more pertinently the risk of aspiration ) may need studies in
larger scale with larger populations.

Therefore the risk profile of a new device (unless it is particularly

unsafe) is unlikely to be established for several years after
introduction.

SUMMARY

There is no solid evidence of any device performing better

than the classic LMA among the first generation SADs.

In the second-generation SADs- The PLMA proved top be very

efficacious and safe in both routine and advanced uses

SAD with a drain tube has become the first choice as the
standard of care.

Other newer SADs like i-gel, SLMA, and LTS-II have increasing
positive evidence of their superiority.

All these developments in the field of SAD paved the way to

take an ever larger role in modern airway management.

THANK YOU