Using the laryngeal mask airway to manage the difficult airway

Before 1990, the choice of an airway device essentially was limited to the facemask or the endotracheal tube. Since then, a number of novel supraglottic airway devices have been developed. The laryngeal mask airway (LMA) was introduced to the United States in 1991 after 3 years of use in the United Kingdom and other countries. Today the LMA has a clearly established role as an airway device in the elective setting when neither the procedure nor the patient require tracheal intubation. Perhaps more importantly, the LMA also has proved extremely useful in managing the difficult airway. This article reviews the use of the various LMA devices to manage the difficult upper airway.     

Intubating laryngeal mask airway for difficult out-of-hospital airway management: a prospective evaluation

Background: Out-of-hospital airway management is a critical skill, demandingexpert knowledge and experience. The intubating laryngeal maskairway (ILMA) is a ventilatory and intubating device which maybe of value in this arena. We evaluated the ILMA for out-of-hospitalmanagement of the difficult airway. Methods: Twenty-one anaesthesia-trained emergency physicians (EPs) completeda training programme and used the ILMA in patients with difficult-to-manageairways. Indications for use of the ILMA included patients withdifficult laryngoscopy, multiple intubation attempts, limitedaccess to the patient’s head, presence of pharyngo-laryngealtrauma, and gastric fluids or bleeding obscuring the view ofthe vocal cords. Results: During the study period, 146 of 2513 patients underwent trachealintubation or alternate rescue airway insertion. In 135 patients,laryngoscopy was performed and Cormack–Lehane view wasrecorded as grade I in 72 (53.3%), II in 45 (33.3%), III in10 (7.4%), and IV in 8 (5.9%). EPs encountered 11 patients (7.5%)with difficult-to-manage airways. ILMA insertion and ventilationwas possible in 10 patients in the first and one patient inthe second attempt. ILMA-guided tracheal intubation was successfulin all patients, in 10 after the first and in 1 after two attempts. Conclusions: In this study, ventilation and intubation with ILMA was successfulin all patients with difficult-to-manage airways. Our data supportthe use of the ILMA as rescue device for out-of-hospital airwaymanagement by staff who have appropriate airway skills and havereceived appropriate training.     

Management of a suspected and unsuspected difficult laryngoscopy with the laryngeal mask airway.

The laryngeal mask airway (LMA) is a new development in airway control. Presented here are two cases of difficult airway management--one anticipated, the other not anticipated--during which the LMA was used effectively.     

Use of intubating laryngeal mask airway for three patients with difficult intubation

We used intubating laryngeal mask airway (ILM) for three patients with difficult intubation, and tracheal intubation was successfully performed through the ILM in all three cases. Difficult intubation in the first case was caused by direct invasion of malignant lymphoma into the right maxillary sinus leading to restricted mouth opening. Neck stiffness due to invasion of metastatic cancer into the cervical spine in the second case and facial trauma caused by traffic accident in the third case gave rise to the difficult intubation. Insertion of the ILM was successfully performed in all the patients following induction of general anesthesia, and the ventilation through the ILM was possible without any difficulties. Subsequently, all patients were intubated through the ILM successfully. We realized that the ILM is useful and should be prepared on the induction of anesthesia in patients suspected of difficult intubation.     

Airway equipment and its maintenance for a non difficult adult airway management (endotracheal intubation and its alternative: face mask,laryngeal mask airway,laryngeal tube)

The airway equipment for a non difficult adult airway management are described: endotracheal tubes with a specific discussion on how to inflate the balloon, laryngoscopes and blades, stylets and intubation guides, oral airways, face masks, laryngeal mask airways and laryngeal tubes. Cleaning and disinfections with the maintenance are also discussed for each type of airway management.     

Another case of use of the ProSealTM laryngeal mask airway in a difficult obstetric airway

Editor—We read with interest the case report by Awan andcolleagues,¹ describing successful use of the ProSeal^TM laryngealmask airway (PLMA) after failed tracheal intubation in a parturientundergoing Caesarean section. After securing the airway withthe PLMA, the authors removed it and tried again to performtracheal intubation. We think that the PLMA can be left in placeand used as a definitive airway after failed intubation in Caesareansection. We report another case where the PLMA     

The laryngeal mask airway facilitates intubation at cesarean section. A case report of difficult intubation

Failed intubation at cesarean section presents the anesthesiologist with a challenge, and may subject both mother and baby to significant morbidity and in some cases, mortality. We report a case of failed intubation at an emergency cesarean section at which intubation was subsequently achieved using a laryngeal mask airway as a guide.     

Use of the laryngeal mask for airway control in difficult intubations in children]

LMA was introduced in clinical practice by Arthur Brain in 1983 as a valuable substitute of tracheal tube in adult who underwent general anaesthesia; since then its applications have been extensively studied. LMA is a relatively new non-invasive ventilatory device which has allowed a radical change in the management of modern general anaesthesia. In this study, the application of LMA is assessed during induction and maintenance of general anaesthesia in children affected by severe facial deformities that could render the placement of the tracheal tube difficult. Three patients were affected by complex malformative syndromes involving the maxillo-facial skeleton and one patient presented a massive teratoma, originating from the orbit. In all these cases, LMA provided a patient airway and a satisfactory ventilation during both induction and the repeated attempts of inserting the tracheal tube; in one case, since the orotracheal intubation failed, LMA has proved to be as effective as the tracheal tube during the maintenance of general anaesthesia. Therefore, LMA is recommended as an essential ventilatory device in the hands of paediatric anaesthesiologists.     

Comparison of the intubating laryngeal mask airway with the fiberoptic intubation in anticipated difficult airway management

BACKGROUND: The intubating laryngeal mask airway (ILMA; Fastrach; Laryngeal Mask Company, Henley-on-Thames, UK) may provide an alternative technique to fiberoptic intubation (FIB) to facilitate the management of the anticipated difficult airway. The authors therefore compared the effectiveness of the ILMA with FIB in patients with anticipated difficult intubation. METHODS: One hundred patients, with at least one difficult intubation criteria (Mallampati class III or IV, thyromental distance < 65 mm, interincisor distance < 35 mm) were enrolled (FIB group, n = 49; ILMA group, n = 51) in this prospective randomized study. Anesthesia was induced with propofol and maintained with alfentanil and propofol after an efficient mask ventilation has been demonstrated. The success of the technique (within three attempts), the number of attempts, duration of the successful attempt, and adverse events (oxygen saturation < 90%, bleeding) were recorded. RESULTS: The rate of successful tracheal intubation with ILMA was 94% and comparable with FIB (92%). The number of attempts and the time to succeed were not significantly different between groups. In case of failure of the first technique, the alternative technique always succeeded. Failures in FIB group were related to oxygen desaturation (oxygen saturation < 90%) and bleeding, and to previous cervical radiotherapy in the ILMA group. Adverse events occurred significantly more frequently in FIB group than in ILMA group (18 vs. 0%, P < 0.05). CONCLUSION: The authors obtained a high success rate and comparable duration of tracheal intubation with ILMA and FIB techniques. In patients with previous cervical radiotherapy, the use of ILMA cannot be recommended. Nevertheless, the use of the ILMA was associated with fewer adverse events.