Procedure

Extraglottic Device

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Extraglottic Device, Supraglottic Device, Laryngeal Mask, Laryngeal Mask Airway, LMA, Esophageal Tracheal Combitube, King Supraglottic Airway, I-Gel

  • Preparations
  • Extraglottic Device - Laryngeal Mask Airway (LMA, I-Gel)
  1. Preferred Extraglottic Device
  2. Used as bridge to definitive airway (especially as back-up for failed intubation, if no airway obstruction)
  3. LMA may be used as conduit to carry fiberoptic scope
  4. Some LMAs (intubating LMA, I-Gel) may be used as conduit to intubate
    1. Avoid removing intubating LMA initially after intubating (risk of dislodging ET Tube)
    2. LMA may be removed later under controlled conditions
  5. Does not secure upper airway (risk of aspiration)
    1. LMAs should be used with orogastric suction (some have specific ports for suction catheter)
  6. Insertion Technique
    1. Select proper LMA size (see below, #3 for small female, #5 for a large male)
    2. Test the LMA cuff by inflating, and then deflate the LMA cuff
    3. Lubricate the closed, convex, posterior LMA surface (Palate side of the device)
    4. Place your index and middle finger into the anterior or airway side of the LMA
    5. Insert the LMA, with the open, concave side facing the inner mouth
      1. Lubricated, posterior side should be against the Palate
    6. Allow the LMA to glide along the Palate and settle into the airway
    7. Inflate the LMA cuff when seated in the airway
  • Preparations
  • Extraglottic Device - Supraglottic Airways (or King LT) or Esophageal Tracheal Combitube (ETC)
  1. Used primarily by prehospital personnel
  2. Balloon inflation (and deflation) on device requires practice
  • Technique
  • Anticipate difficult Extraglottic Device (Mnemonic: RODS)
  1. Restricted mouth opening
  2. Obstruction of the upper airway or Larynx
  3. Distorted or disrupted airway
  4. Stiff lungs requiring increased Ventilatory pressures (Asthma, COPD, ARDS, term pregnancy)
  • Precautions
  1. Vomiting
    1. Extraglottic Devices including LMA do not protect the airway and may increase risk of aspiration (by deflecting vomit into airway)
    2. Consider pre-treatment with Antiemetics (e.g. Zofran)
  2. High pressure, non-compliant lungs (Asthma or COPD)
    1. Extraglottic Devices including the LMA cannot generate airway pressures above 25 mmHg
  3. Over-inflation of balloon (especially LMA)
    1. Avoid over-inflating with LMA (un-seats the LMA, and pushes the LMA up and out of airway)
    2. LMA #3 (small female): Inflate 10cc air
    3. LMA #4 (large female, small male): Inflate 15cc air
    4. LMA #5 (large male): Inflate 20cc air
  • Resources
  1. Airway Cam (Levitan)
    1. http://www.airwaycam.com/
  2. Airway World (Walls, requires free registration to view videos)
    1. https://amec.6connex.com/portal/airwayworld/login
  • References
  1. Levitan (2013) Practical Airway Management Course, Baltimore
  2. Walls (2012) Difficult Airway Course, Chicago