Laryngeal Mask Airway for Prehospital Use

1
Laryngeal Mask Airwayfor Pre-hospital Use
2
What is the LMA Airway?

• Supraglottic, non-invasive airway device
• Designed to maintain a patent airway in emergency
  patients
• In immediate need of an airway and
• In whom tracheal intubation has failed or is not
  an option
• In whom the benefit of establishing an airway
  outweighs the risk of regurgitation and
  aspiration

3
LMA Airway History

• Introduced in the U.S. anesthesia market in 1992
  emergency market in 1996
• Currently used in 30 of all surgeries
• Estimated use in over 100 million patients
  worldwide
• More than 2,000 publications

4
LMA Airway History

• Part of American Association of Anesthesiologists
  (ASA) Difficult Airway Algorithm since 1993
• Part of National Emergency Airway Management
  Course (NEAMC) Difficult Airway Failed Airway
  Algorithms since 1998
• Recommended as an alternative airway device by
  American Heart Association (AHA) International
  Liaison Committee on Resuscitation (ILCOR) in 2000

5
AHA Guidelines on Ventilation

• Tracheal intubation should only be attempted by
  experienced providers
• BLSLMA airway is alternate airway for providers
  not trained in intubation
• ACLSClass IIa device acceptable, safe, and
  useful. Standard of care
• PALSIndeterminate promising intervention
• NeonatalAlternative in cannot intubate, cannot
  ventilate situation

6
LMA Airway Advantages

• Easy to learn and retain skill
• Rapid, blind insertion without regard to patient
  position
• Non-invasive

7
LMA Airway Advantages

• Advantages over intubation
• No direct visualization needed can be performed
  despite secretions and blood
• No bronchial or esophageal misplacement
• Less traumatic and hemodynamically stimulating

8
LMA Airway Advantages

• Advantages over face mask
• More effective ventilation
• Less gastric insufflation
• One-handed ventilation
• More secure

9
LMA Airway Advantages

• Advantages over Combitube
• Less traumatic
• Less invasive
• Less cervical spine motion
• Available in all patient sizes
• Cost-effective
• Latex-free

10
AHA Recommended Airway Devices
11
Summary

• New AHA guidelines recommend the use of an
  alternative airway device
• Clinical experience and large number of clinical
  papers document the efficacy and safety of
  LMAairways
• LMA airways have many advantages as an
  alternative airway including ease of insertion,
  ease of training, and effective ventilation
  without being invasive

12
LMA Airway Placement

• Provides a seal around the laryngeal inlet once
  the LMA airway is inserted and the cuff inflated
• Once inserted, the distal tip of the LMA cuff
  presses against the upper esophageal sphincter

13
Types of LMA Airways for Pre-hospital Use

• LMA-Unique
• The disposable LMA-Classic
• LMA-Classic
• Reusable LMA airway for pediatrics
• LMA-Fastrach
• Reusable intubating LMA airway

14
Types of LMA Airways for Pre-hospital Use
Pediatric LMA-Unique to be available September
2003.
15
LMA Airway Insertion

• Insertion should not be attempted in patients who
  are not profoundly unconscious and who may resist
  LMA airway insertion

16
LMA-Unique LMA-ClassicPre-Insertion
Preparation

• Select correct size for patient have syringe and
  lubricant available.
• Inflate to check cuff integrity then fully
  deflate by pressing on a flat surface.
• Deflate cuff to spoon shape - no wrinkles on
  distal end.
• Lubricate only the posterior tip. Hold the LMA
  device like a pen, with the index finger at the
  cuff/tube junction.

17
LMA-Unique LMA-ClassicInsertion

• With the head in the sniffing position, flatten
  the LMA airway tip against the hard palate.
  Keep the LMA airway tube parallel to the
  patients chest.
• Fully extend the index finger, following the
  contours of the hard and soft palates and press
  cranially toward the other hand.
• Advance the LMA device until definite resistance
  is felt.
• Note the flexion of the wrist.

18
LMA-Unique and LMA-ClassicInsertion

• Gently keep the LMA device in place with the
  non-dominant hand while removing the index
  finger.
• Inflate the cuff with enough air to obtain a
  seal. Frequently half of the maximum volume is
  sufficient to achieve a seal.

19
LMA-Fastrach

• Facilitates blind intubation
• Allows continuous ventilation during and between
  intubation attempts
• Single-handed insertion from any position without
  moving head and neck
• No need to place fingers in the mouth
• Comes with wire-reinforced LMA-Fastrach
  endotracheal tube

8.0 ETT is also available
20
LMA-Fastrach Insertion

• Place head and neck in the neutral position
• Fully deflate cuff to spoon shape-no wrinkles
• Lubricate posterior mask tip and rub lubricant
  over palate
• Curved part of metal tube in contact with chin

21
LMA-Fastrach Insertion

• Mask tip flat against palate
• Swing mask in circular motion, keeping pressure
  against the posterior pharynx
• Inflate mask to just seal pressure (50
  maximum)
• Use up/down, right/left movements to find best
  airway position with minimum leak

22
Intubating through the LMA-Fastrach

• Do not intubate when esophageal
• or pharyngeal pathology is present
• Check the ETT cuff prior to use
• Lubricate the ETT and gently pass
  the ETT into the LMA-Fastrach tube,(rotating and
  moving the ETT up and down) to
  distribute the lubricant

23
Intubating through the LMA-Fastrach

• The ETT transverse line corresponds to the point
  at which the ETT is about to enter the mask
  aperture
• Use the handle to gently lift the device 2-5 mm
  to increase seal pressure and optimize alignment
  of the axes with the trachea
• Advance the ETT until intubation is complete
• Inflate cuff and confirm intubation

24
Removal of LMA-Fastrachover Endotracheal Tube

• Ensure oxygenation
• Remove ETT connector
• Deflate LMA-Fastrach cuff
• Swing mask out of pharynx, applying
  counterpressure to the ETT with finger
• Slide the LMA-Fastrach over the stabilizer rod
  until the mask is clear of the mouth

25
Removal of LMA-Fastrach over Endotracheal Tube

• Remove the stabilizer rod and hold the ETT steady
  at the level of the incisors
• Remove the LMA-Fastrach completely, gently
  unthreading the inflation line and pilot balloon
  of the ETT
• Replace ETT connector and reconfirm placement

26
LMA-Fastrach Summary

• Able to ventilate patient while preparing for
  definitive airway
• Alternative to surgical airway
• Able to place in any patient position
• With limited access
• With one hand
• Blind insertion no laryngoscopy
• Reliable adjunct/backup for RSI