Supraglottic, non-invasive airway management device

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What is an LMA?

• Supraglottic, non-invasive airway management
  device
• 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
• Designed to maintain/temporize an airway in
• Patients with immediate need of an airway
• Patients with failed tracheal intubation or in
  whom tracheal intubation is not an option
• Patients in whom the benefit of establishing an
  airway outweighs the risk of regurgitation and/or
  aspiration

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LMA Placement

• When fully inserted using the recommended
  insertion technique, the distal tip of the LMA
  cuff presses against the upper esophageal
  sphincter
• Its sides face into the pyriform fossae and the
  upper border rests against the base of the tongue

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LMA History

• The Laryngeal Mask Airway (LMA) was invented and
  designed by Dr. A.I.J. Brain in the East End of
  London in 1981. While a practicing
  anesthesiologist, Dr. Brain identified the need
  for better safety, reliability and the ease of
  insertion of airway management devices.
• Introduced to the U.S. anesthesia market in 1992
  and to the emergency market in 1996
• Included in and supported by the American Heart
  Association Resuscitation Guidelines
• Used more than 250 million times worldwide
• Currently used in 38 of all surgeries
• Supported by over 2,800 published references and
  growing

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AHA Guidelines on Ventilation

• Tracheal intubation should only be attempted by
  experienced providers
• BLS The LMA is an alternate airway for
  providers not trained in intubation
• ACLS The LMA is a class IIa device
  acceptable, safe and useful. Standard of care
• PALS Indeterminate The LMA is a promising
  intervention
• Neonatal The LMA is an alternative in cannot
  intubate, cannot ventilate situation

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Characteristics LMA Unique LMA Fastrach(Reusable/Single Use) BVM Combitube ETT
Ease of use ? ? ? ?
Non-invasive ? ? ?
Hemodynamic stability upon placement ? When not used with ETT ?
Improved oxygen saturation ? ? ? ?
Avoidance of endobronchial/esophageal intubation ? When not used with ETT ? Accommodates
Can be used without manipulating head neck ? ?
Inserted in any position/limited access ? ?
Designed to protect against aspiration When used with ETT ? ?
Single-handed ventilation ? ? ? ?
Less user fatigue ? ? ? ?
Ease of training ? ? ?
Retention of skill ? ? ? If performing gt6 per year
Latex-free ? ? Requires special purchase ?
Pediatric-Adult sizes ? Large children-adults ? ?
AHA Recommended Airway Devices
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LMA Advantages

• Advantages over the face mask
• Airway quality generally unaffected by anatomical
  factors (e.g., edentulous, bearded, southern
  Asian, neonatal patients) or by facial damage
• Provides clearer airway
• Airtight seal more easily obtained
• Compression of eyeballs and face avoided
• Higher concentration of inspired oxygen
• Lower incidence of gastric insufflation,
  regurgitation and aspiration in CPR studies
• Protects against aspiration of blood from nasal
  and oral cavities
• Less manipulation of head and neck required in
  those with suspected cervical spine injuries
• One hand is free for other important tasks

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LMA Advantages

• Advantages over the ETT
• Insertion easier to learn
• Higher levels of skill retention over time
• Higher first time placement rates
• Shorter time to achieve an adequate airway
• Plentiful supply of routine cases on which to
  gain experience
• Laryngoscopy unnecessary
• Neuromuscular blockade not required
• Avoids risk of esophageal and endobronchial
  placement
• Placement easily achieved with MILS of cervical
  spine applied
• Less invasive of and less traumatic to
  respiratory tract
• Lower incidence of laryngospasm and bacteraemia
• Reduced risk of pulmonary barotrauma

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• KEY REFERENCE
• (Katz SH, Falk JL. Misplaced endotracheal tubes
  by paramedics in an urban emergency medical
  services system. Ann Emerg Med. January
  20013732-37. )
• Prospective observational study of patients
  intubated in the field by paramedics in order to
  determine the incidence of unrecognised misplaced
  endotracheal tubes (ETTs) in a large urban,
  decentralised EMS system? On arrival at
  hospital, ETT position was assessed by an
  emergency physician using a combination of
  auscultation, end-tidal carbon dioxide (EtCO2)
  monitoring, and direct laryngoscopy
• 27/108 (25) of patients had improperly placed
  endotracheal tubes ? 18/27 (67) of misplaced
  tubes were in the oesophagus and 10/18 (56) of
  these patients died in the ED
• 9/27 (33) had the tip of the tube in the
  hypopharynx above the vocal cords and 3 (33) of
  these patients died in the ED.
• Ann Emerg Med 2001

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• SELECTED REFERENCE (1)
• (Verghese C, Prior-Willeard PF, Baskett PJ.
  Immediate management of the airway during
  cardiopulmonary resuscitation in a hospital
  without a resident anaesthesiologist. Eur J Emerg
  Med. 1994 Sep1(3)123-5)
• When the resident anaesthetist was withdrawn from
  the CPR team in a 407-bed UK hospital, nurses
  having been trained to use the LMA for the
  initial management of the airway in CPR
• ? Use of the LMA increased from 2 to 64 cases
• ? Use of the endotracheal tube decreased from
  57 to 20 cases
• Return of spontaneous circulation increased
  from 36 to 61 of cases
• There were no instances of failure to
  maintain the immediate airway
• (during the first year when compared with the
  previous 12 months)
• Eur J Emerg Med 1994

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SELECTED REFERENCE (4) (Deakin CD, Peters R,
Tomlinson P, Cassidy M. Securing the prehospital
airway a conparison of laryngeal mask insertion
and endotracheal intubation by UK paramedics.
Emerg Med J 20052264-67) Paramedics with the
Hampshire Ambulance Service trained in the use of
the LMA and ETT were asked to secure the airway
in patients undergoing routine anaesthesia ?
Even under optimal conditions, 30 of attempts at
tracheal intubation by paramedics were
unsuccessful ? Laryngeal mask insertion was
successful in 80 of patients in whom
endotracheal intubation had failed The authors
concluded that a disposable laryngeal mask has a
higher success rate in securing the airway and,
overall, secures the airway more reliably than
endotracheal intubation Emerg Med J 2005
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Patients die from
Failure to Ventilate Failure to Oxygenate
Not from Failure to Intubate
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LMA Advantages

• Advantages over the Combitube
• Latex-free
• Cost-effective
• Less invasive of and less traumatic to
  respiratory tract
• Less manipulation of head and neck required in
  those with suspected cervical spine injuries
• Does not require removal for tracheal intubation
• Ventilation and oxygenation can remain
  uninterrupted

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LMA Fastrach Single Use Ideal for Pre-hospital
Use

• Rescue device for ACLS/air emergency units in
  failed/difficult intubation
• Single use
• Temporizing device, functions as alternative to
  bag-valve-mask

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LMA Fastrach Single Use Size Chart
Mask Size Patient Size LMA Fastrach Single Use
Size 3 Children 30 50 kg X
Size 4 Adults 50 70 kg X
Size 5 Adults 70 100 kg X
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LMA Fastrach Single Use

• Simple, fast insertion technique to achieve
  ventilation
• Success rate is virtually 100 for establishing
  an airway
• Allows ventilation between intubation attempts
• High intubation success rate both blind and
  fiberoptic assisted
• Supplied ready to use including syringe and
  lubricant
• 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 Single
  Use Endotracheal Tube and Stabilizer Rod

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LMA Fastrach Single Use

• Rigid, anatomically curved airway tube that is
  wide enough to accept an 8.0 mm cuffed ETT and is
  short enough to ensure passage of the ETT cuff
  beyond the vocal cords
• Rigid handle to facilitate one-handed insertion,
  removal, and adjustment of the device's position
  and can be pressed anteriorly to increase seal
  pressure during unexpected regurgitation
• Epiglottic elevating bar in the mask aperture
  which elevates the epiglottis as the ETT is
  passed through and a ramp which directs the tube
  centrally and anteriorly to reduce the risk of
  arytenoid trauma or esophageal placement

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LMA Fastrach Success Rate

• Successful intubation in a variety of difficult
  airway scenarios, including awake intubation, has
  been described by G. Caponas, with the overall
  success rate being approximately 98
• G Caponas. Intubating Laryngeal Mask Airway.
  Anaesthesia and Intensive Care, Vol. 30, No. 5,
  October 2002

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Why Use the LMA Fastrach Single Use for Tracheal
Intubation

• Allows easy intubation without laryngoscopy
• Laryngoscope vs. LMA Fastrach
• Laryngoscope Distortion of the anatomy to align
  axis may not be possible in some patients due to
  anatomy, surgery, radiation or secretions
• LMA Fastrach Single Use No tissue distortion
  Because it facilitates ventilation between
  intubation attempts, it allows intubation to take
  place unhurriedly with minimal risk of
  desaturation
• NOTE Although the LMA Fastrach is ideal for
  difficult airway situations, it is strongly
  recommended that the device be used routinely in
  elective, non-difficult airway patients to
  develop competency

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Benefits of the LMA Fastrach Single Use in
Emergency Medicine

• Rescue device for failed or difficult airway
• Temporizing
• Able to ventilate patient while preparing for
  definitive airway
• Alternative to surgical rescue
• Able to place in any patient position with one
  hand
• Facilitates tracheal intubation
• Blind insertion
• No laryngoscopy or fiberoptics needed
• Excellent adjunct/backup for RSI

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The LMA in Emergency Care

• Cardiac arrest
• Near drowning
• Drug overdose (e.g. opiates)
• Inhalation of smoke or toxic fumes
• Trauma including patients with serious facial
  or head trauma
• For rescue ventilation after failed intubation
• Inability to maintain an airway or oxygenation
  especially where rapid control is essential

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LMA Fastrach Single Use Indications

• Guide for intubation of the trachea
• Alternative to the face mask for achieving and
  maintaining control of the airway in routine and
  emergency situations, including anticipated or
  unexpected difficult airways
• Method of establishing a clear airway in the
  profoundly unconscious patient with absent
  glossopharyngeal and laryngeal reflexes

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LMA Fastrach Single Use Contraindications and
Warnings

• When used alone, does not protect from
  regurgitation and aspiration
• Risk of regurgitation/aspiration must be weighed
  against the potential benefit of establishing an
  airway
• Intubation through the LMA Fastrach Single Use
  may not be appropriate when esophageal or
  pharyngeal pathology is present

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LMA Fastrach Single Use Insertion

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

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LMA Fastrach Single Use Insertion

• Mask tip flat against hard 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

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Intubating through the LMA Fastrach Single Use

• 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

ETT depth marker
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LMA Fastrach Single Use Intubation

• 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

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Removal of LMA Fastrach Single Use over ETT

• Ensure oxygenation
• Remove ETT connector
• Deflate LMA Fastrach cuff
• Swing mask out of pharynx, applying counter
  pressure to the ETT with finger
• Slide the LMA Fastrach over the Stabilizer Rod
  until the mask is clear of the mouth
• Remove Stabilizer Rod and gently unthread the
  inflation line and pilot balloon of the ETT
• Replace the ETT connector and reconfirm placement

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13 Reasons the LMA Fastrach Single Use is
Suitable for Pre-hospital Use

• No need for laryngoscopy
• Head and neck in neutral alignment for insertion
• Neuromuscular blockade not necessary
• At least as easy to insert as the standard LMA
• Can be introduced blindly with one hand from any
  position
• Rigid handle facilitates insertion, mask
  positioning (optimizing ventilation) and can be
  pressed anteriorly to increase seal pressure
  during unexpected regurgitation
• Requires an inter-dental gap of only 20mm
• No need to insert finger in patients mouth
• Rigid airway tube resists occlusion by biting
• Suitable as a rescue airway device in its own
  right
• Facilitates seamless progression to tracheal
  intubation
• Permits ventilation between/during intubation
  attempts
• Available as a disposable, single use device

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LMA in Pre-hospital Summary

• AHA recommended alternative airway
• Clinical experience with over 2,800 clinical
  references which document efficacy and safety
• The LMA has many advantages as an alternative
  airway including ease of insertion, ease of
  training, less invasive/traumatic, cost-effective
  and effective ventilation

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Further Information

• For further information regarding the LMA
  Fastrach Single Use, including instruction
  manuals, insertion guide and tip sheet, please
  visit www.lmana.com or call 1-800-788-7999