LMA Insertion

I've inserted the LMA with both partially filled and completely deflated cuffs. I have not found any difference with ease of insertion. It also depends on how wide the patient's mouth opening is. If the patient has a small mouth opening, then deflating the cuff will help ease its insertion.

Vince.

CRNP/CRNA

I usually do not like to deflate because sometimes I think with those cheapy disposable LMAs the cuff can curl under. I usually remove them inflated too to catch all the mucus in the back of the throat as it is coming out.

It will always be easier to insert if you sniff the pt just as if you were to tube them...if all else fails, use the toilet plunger insertion method.

In the essence of clinical topics, I would like a discussion on how you insert LMAs. Do you do it with cuff totally deflated or partially inflated. I do it both ways, and am not sure if one is better than the other. Would love to hear other opinions. I will also cross-post this on another forum and compare the answers.

I have been involved in instruction on the difficult airway for 14 years and have had numerous discussions with Dr. Archie BRain the LMA inventor. He feels that although there are many ways to insert the LMA the conventional, fully deflated remains the easiest method of insertion. I would agree with him. Additionally if you consider a LMA as a rescue device, partially inflating the LMA usually causes the epiglottis to fold over the laryngeal opening making intubation with a 6.0 MLT endotrachael tube or fiberoptic assisted trachael intubation difficult or impossible.

What exactly is the intended use of the LMA outside the acute surgical situation? I once received a patient from surgery with LMA in place with the plan to keep the patient intubated (are they considered intubated?). Given the fact that it sits above the cords I didn't feel it was as stable an airway for this setting? Since patients usually don't come to the ICU with these I didn't ask and only noticed it was an LMA once the anesthesia provider had left the scene. Is this okay? Educate me please!

What exactly is the intended use of the LMA outside the acute surgical situation? I once received a patient from surgery with LMA in place with the plan to keep the patient intubated (are they considered intubated?). Given the fact that it sits above the cords I didn't feel it was as stable an airway for this setting? Since patients usually don't come to the ICU with these I didn't ask and only noticed it was an LMA once the anesthesia provider had left the scene. Is this okay? Educate me please!

Having an LMA in place is absolutely NOT the same as being intubated. As you said, because the LMA sits above the cords, the airway is technically not protected (the patient can still spasm or aspirate). In the operating room, the LMA is used in place of a mask anesthetic, pretty much just to free up the provider's hands and allow you to take care of other things. In addition, an LMA can be used as a rescue airway device for a difficult intubation. It can be used to ventilate a patient who cannot be ventilated by a mask/ambu and also to place an ETT through (LMA fastrach, etc..). Many providers are using an LMA as a replacement for an ETT and while I would not want to criticize or question anyone else's practice, it is not intended to be used in this manner (at least not yet). Case in point, is the current case in Texas in which an LMA was used on an obese patient with CAD who aspirated and died. Having said that, I do know that in Europe, they use LMAs a LOT more liberally than we do here (lap choly's, c-sections, with a ventilator). Hope that helps!

Some EMS agencies are using the LMA as a rescue airway when the patient can't be tubed or properly ventilated with a BVM.

I have done both ways. With it deflated i find it folds back easily and usually requires use of the second hand to reposition the tip. With it partially filled it can be difficult to get in the mouth past the tongue but overall easier to insert.

LMA to the ICU? nice airway. All the protection of an oral airway. I dont know the specifics, but I would personally be embarrassed to send a pt to the ICU with an LMA, a lot like sending a post op carpal tunnel to the SICU for recovery. and no, the pt is not intubated.

A trick I was taught is to leave the LMA inflated and attach the syringe for air inflation to the cuff without the syringe plunger. As you insert the LMA the appropriate amount of air for easy insertion will be expelled through the syringe. So far this has worked like a charm.

LMA to the ICU? nice airway. All the protection of an oral airway. I dont know the specifics, but I would personally be embarrassed to send a pt to the ICU with an LMA, a lot like sending a post op carpal tunnel to the SICU for recovery. and no, the pt is not intubated.

We have had this as well.. post-op heart with an LMA in the sicu, apparently a 2.5 hour "impossible intubation".

I've seen one patient in my CVICU that came out of surgery with an LMA. He remained "intubated" for 24 hours. The reason for the LMA was that he was an extremely difficult intubation.

Of all the patients I've had, he complained the most after extubation. He said it was completely horrible, and he had been intubated with an ETT in the past.