SOOD : LMA VARIANTS 275 Indian J. Anaesth.

2005; 49 (4) : 275 - 280

M.D., F.F.A.R.C.S.
Chairperson
Dept. of Anaesthesiology, Pain and Perioperative Medicine
Sir Ganga Ram Hospital, New Delhi, INDIA.
LARYNGEAL MASK AIRWAY AND ITS VARIANTS
Dr. Jayashree Sood
Introduction
Airway management is one of the most important
skills in the field of anaesthesiology, and inability to secure
the airway can lead to catastrophic results. Before 1990,
only the face mask and the endotracheal tube (ETT) were
the available airway devices. Since then several supraglottic
airway devices have been developed, of which the laryngeal
mask airway (LMA) is the most popular one.
1,2
Laryngeal Mask Airway - Classic
The LMA was conceived
and designed by Dr. Archie Brain
in U.K. in 1981. Following
prolonged research, it was released
in1988.
1
At an early stage in its
development, the inventor realized
its potential in the management of
the difficult airway.
1,3-6
Today, it has a clearly
established role as an airway
device in the elective setting where neither the procedure
nor the patient requires tracheal intubation. It has now
become an established part of routine airway management
and has proved extremely useful in managing the difficult
airway.
Concept and design
1,4,7,8
The LMA fills a niche between the face mask (FM)
and tracheal tube (TT) in terms of both anatomical position
and degree of invasiveness. It is manufactured from medical
grade silicone rubber and is reusable.
It consists of 3 main components (fig. 1) : An airway
tube, inflatable mask and mask inflation line. The airway
tube is slightly curved to match the oropharyngeal
anatomy, semirigid to facilitate atraumatic insertion and
semitransparent, so that condensation and regurgitated
material is visible. A black line runs longitudinally along
its posterior curvature to aid in orientation. The distal
aperture of the airway tube opens into the lumen of an
inflatable mask and is protected by two flexible vertical
rubber bars, called mask aperture bars (MAB), to prevent
the epiglottis from entering and obstructing the airway.
The inflatable mask is oval shaped with a broad,
round proximal end and a narrower, more pointed distal
end. It has an inflatable cuff and a semirigid, concave,
shield like backplate. The cuff is attached to the outer rim
of the backplate.
The inner aspect of the mask is called the bowl,
which is comprised of the distal aperture, mask aperture
bars, backplate and the inner aspect of the inflatable cuff.
The mask inflation line, which is attached to the
most proximal portion of the cuff in the midline consists of
four parts, the long narrow inflation line itself, the inflation
indicator balloon (pilot balloon), a metallic valve and the
syringe port. The valve, which has a white coloured core
is made from polypropylene and has a stainless steel spring
valve. The LMA is available in eight sizes (table 1), from
neonates to large adults, 1 to 6 and two half sizes 1.5 and
2.5. The cuff, but not the tube, has identical proportions
among sizes; it gets about 15% larger for each size.
Table - 1 : Classic LMA Specifications
4
Mask size Patient weight (kg) Maximum inflation
volume (mg)
1 < 5 4
1.5 5 10 7
2 10 20 10
2.5 20 30 14
3 30 50 20
4 50 70 30
5 70 100 40
6 > 100
Anatomy
1,8
The cuff is pressed aganist several structures in
sequence the hard palate, the soft palate, the naso/
oropharyngeal and then the hypopharyngeal portion of the
posterior pharyngeal wall.
The ideal final anatomic position occupied by the
classic LMA is as follows:
The distal cuff sits in the hypopharynx at the junction
of the upper oesophagus and respiratory tracts, where it
forms a circumferential low pressure seal around the glottis.
Superiorly, the upper part of the mask lies under the base
of the tongue, allowing the epiglottis to rest within the bowl
275
Fig. 1 : LMA - Classic
INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005 276 PG ISSUE : AIRWAY MANAGEMENT
of the mask at an angle probably determined by the extent
to which passage of the mask has deflected it down-wards.
When inflated, it lies with the tip resting against the upper
esophageal sphincter, the sides facing the pyriform fossae
with the upper surface behind the base of the tongue and the
epiglottis pointing upwards. The aperture of a properly
positioned LMA aligns itself anatomically with the laryngeal
inlet.
The tip of the LMA cuff lies at a variable depth
behind the cricoid cartilage; and the posterior surface
immediately anterior to the C
2
to C
7
cervical vertebrae.
The laryngeal inlet can be tipped anteriorly by the inflated
LMA cuff when cricoid pressure is applied; this may explain
why blind intubation via the LMA is more difficult with
cricoid pressure applied.
Indications
Elective short surgical procedures under general
anaesthesia excluding head and neck surgery
Rescue airway in cannot intubate can ventilate
and cannot intubate, cannot ventilate scenario if
the problem is supraglottic in nature, since successful
use of the LMA does not require the constellation of
factors required for direct laryngoscopy and
tracheal intubation.
1,5,9
In 1996 it entered the American
Society of Anesthesiologists difficult airway
algorithm in five different places, both as a ventilatory
device (airway) and a conduit for endotracheal
intubation.
1,2,8,9
Cardiopulmonary resuscitation
1,7,8
Contraindications
2,4
Mouth opening less than 1.5 cm
Poor lung compliance
Airway pressure more than 20 cm of H
2
O
Non fasting patients
Insertion technique
1,2,4,7,9,10
LMA insertion can be considered in the context of
swallowing both in terms of the space it occupies and the
type of reflex response it elicits. The insertion technique
does not require the use of a laryngoscope or muscle
relaxants and is designed to imitate the mechanism whereby
the food bolus is swallowed.
Preparation of the LMA and the patient is essential
for successful placement. Lubrication of the mask should
avoid the use of local anesthetics in order to preserve
protective reflexes against aspiration. A selection of LMA
sizes should be available in addition to the one most likely
to fit because the anatomical features of the larynx cannot
always be predicted from the physical examination. Most
of the induction agents can be used to facilitate placement
of the LMA. The adequate depth of anaesthesia for LMA
placement is significantly less than that for tracheal
intubation.
Several insertion techniques have emerged to
complement the original technique which was described
when the LMA was introduced. The standard technique
involves a completely deflated LMA, held like a pen guided
into the pharynx with the index finger of the operator at the
junction of the tube and the bowl, with the operator at the
head of the patient and the LMA aperture facing caudally.
With the head extended and the neck flexed by using the
hand under the occiput, under direct vision, the tip of the
cuff is pressed upwards against the hard palate. The LMA
is advanced into the hypopharynx till a resistance is felt.
The cuff is then inflated with just enough air to seal, to
intra cuff pressure around 60 cms H
2
O. A common alternative
technique popular in children described by McNicol, consists
of inserting a partially inflated LMA into the pharynx above
the epiglottis with the aperture facing cranially, the LMA
is then turned 180 degrees before advancing it into its final
position.
11
The LMA should then be secured after insertion in
such a way, so as to prevent rotation and movement
cranially. If surgical access allows, a preferred way to
connect the LMA to the anaesthesia circuit is to direct the
circuit connection caudally and bring the circuit limbs down
on the side of the patients neck and head.
Signs of correct LMA placement
4,8,9
a. Slight outward movement of the tube upon LMA
inflation.
b. Presence of a small oval swelling in the neck around
the thyroid and cricoid area.
c. No cuff visible in the oral cavity.
d. Expansion of chest wall on bag compression
Before taping the LMA in place, a bite block is
inserted to stabilize the LMA and prevent tube occlusion.
Emergence technique
Removal of the LMA can be accomplished either
during deep anesthesia or after protective reflexes have
returned.
4,7,8
Pathophysiology
Pharyngeal microcirculation is unimpaired at low
to moderate cuff volumes for all LMA devices (except
intubating LMA). The LMA is a relatively noninvasive
airway compared with a tracheal tube, and it causes minimal
disturbance of the cardiovascular and respiratory system.
The incidence of sore throat is minimal because the cords
SOOD : LMA VARIANTS 277
are not penetrated. The haemodynamic stress response to
LMA insertion is less pronounced than during tracheal
intubation during induction, maintenance and emergence from
anaesthesia. Less anaesthetic is required to tolerate the
LMA once the device is insitu.
1,8
LMA and aspiration
Although the correctly placed LMA tip lies against
the upper esophageal sphincter, the LMA does not isolate
the respiratory tract from the gastrointestinal tract and
does not protect the lungs from regurgitated gastric contents.
The glottic seal is usually lost at peak airway pressures
above 20 cms H
2
O.
1,4
Incidence of aspiration with the
LMA is 2 per 10,000.
1
LMA and the difficult airway
1,2,7,8
Several design features make possible its use as an
airway intubator, like the wide bore of the LMA tube, the
width and elasticity of the aperture bars, the angle at which
the tube enters the bowl of the mask, anatomic alignment
of the LMA aperture with the glottis and the low pressure
seal allowing synchronous patient ventilation.
However there are several problems associated with
this. The internal diameter of the airway tube is too small
to accommodate a normal sized tracheal tube, and it is too
long to ensure that a normal length tracheal tube will
penetrate the vocal cords. The mask aperture bars interfere
with the passage of the tracheal tube. Removal of the LMA
may be difficult after successful intubation due to the length
of the airway tube. Direct blind intubation has a success
rate around 55%. Success is reduced by cricoid pressure,
and is similar for normal and abnormal airways.
Fiberoptic guided intubation via the LMA has higher
success rate and causes less trauma. It can be performed
directly by inserting the tracheal tube over the fiberoptic
scope or indirectly using a guide first.
The manufactures warranty for LMA classsic is for
40 uses, but deterioration in performance does not occur
until 80-100 uses. Despite high capital costs, the LMA is
cost effective compared to tracheal tube.
8
LMA variants
At present, variations include a reinforced/ flexible
LMA (LMA-Flexible), LMA specifically designed for
tracheal intu-bation (LMA-Fastrach), single-use LMA
(LMA-Unique) and LMA with an integral gastric access/
venting port (LMA-ProSeal).
I. Flexible laryngeal mask airway (reinforced LMA)
2,7,8
In 1990, two reports appeared in the journal
Anaesthesia describing kinking of the LMA tube. The
flexible LMA (fig. 2) was designed by Brain and released
in 1992 to prevent tube occlusion,
improve surgical access and prevent
cuff displacement during head, neck
and oropharyngeal surgery.
4
It is made from medical
grade silicone and rubber and is
reusable. It consists of a Classic
LMA connected to a flexible, wire
reinforced tube that is longer and
narrower than the Classic LMA. The wire reinforcement
prevents kinking, the additional length allows the anaesthesia
breathing system to be connected further from the surgical
field and the reduced diameter allows more room in the
mouth. It is preferable for intra-oral surgery especially
adenotonsillectomy.
The cuff and inflation line are identical to the Classic
LMA. It is available in six sizes 2, 2.5, 3, 4, 5 and 6.
II. The intubating LMA - Fastrach
2,5,8
Since the Classic LMA
was not ideally suited to aid (blind)
tracheal intubation, the primary
design goal for a new intubating
LMA was to produce an intubating
system that eliminated the need
for anatomical distortion and that
did not require manipulation of
the head and neck, and thus
increased its utility in patients
with cervical spine pathology. It
was released in 1997.
It consists of three parts the ILMA itself, the
tracheal tube and a stabilizing rod.
The ILMA is a rigid, anatomically curved airway
tube made of stainless steel with a standard 15 mm
connector. The tube is wide enough to accommodate an 8.0
ETT and short enough to ensure passage of the ETT beyond
the vocal cords. A rigid handle attached to the tube facilitates
one handed in sertion, removal, and most importantly,
adjustment of the devices position so that the aperture
directly opposes the larynx. It has a single flap, the epiglottic
elevating bar.
It is available in three sizes (3,4,5) that correspond
to the cuff size of the original LMA. After adequate
lubrication insertion of the ILMA may be easier than the
original LMA because the rigid tube follows the anatomic
curve of the palate and posterior pharyngeal wall and ones
index finger does not have to enter the mouth. Once
positioned correctly, the ILMA can be connected to a circuit
and used as an airway device. There are several maneuvers
Fig. 3 : Intubating LMA
Fig. 2 : Flexible LMA
INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005 278 PG ISSUE : AIRWAY MANAGEMENT
to facilitate ILMA guided intubation, of which the seal
optimization (Chandis maneuver) consists of two sequential
steps: obtaining the best seal by moving the cuff in the
pharynx in the sagittal plane, and then using the handle to
slightly lift (and not tilt) the ILMA away from the posterior
pharyngeal wall.
It is recommended strongly that the special supplied
ETT be used for intubation. This sili-cone tube is soft
tipped, straight, wire reinforced and cuffed. It exits the
ILMA at an angle that facilitates passage through the glottis.
Tracheal tubes available are 7.0, 7.5 and 8 mm internal
diameter and each fits through each of the three ILMA.
To remove the ILMA once the trachea is intubated,
one should remove the 15-mm ETT connector while the
ETT cuff remains inflated. Then swing the ILMA out of the
pharynx and mouth while applying counter-pressure to the
ETT. To hold the ETT tube in place, the stabilizing rod (20
cm) is opposed to its proximal end, which effectively
increases the length of the ETT and permits sliding of the
ILMA out of the mouth.
LMA C Trach
12
LMA C Trach is a
modification on the blind
on blind technique of the
LMA Fastrach wi th
integrated fibreoptics.
It provides a direct
view of the larynx with real
time visualization of the
tracheal tube passing through the vocal cords. It has two
integrated fiberoptic channels a light guide to transfer
light to illuminate the larynx and a 10,000 pixel image
guide to transfer the image of the larynx to the viewer.
There is a modified epiglottic elevating bar which
optimises the light source and enables uninteruppted image
transmission to the viewer.
It is fully autoclavable unlike conventional endoscopes
and is yet to be introduced in India.
III. The disposable LMA (UNIQUE)
8
(fig. 5)
It was synthesized and released
i n 1998 for cardi opul monary
resuscitation because the silicone based
Classic LMA was too expensive and
needed proper sterilization to prevent
cross infection for this rare indication.
The disposable LMA is made of clear
medical grade polyvinyl chloride. The
airway tube is more rigid and the cuff
thicker. It is supplied sterile and for single use only. It is
currently available in sizes similar to the Classic LMA.
9
IV. ProSeal Laryngeal mask airway (LMA ProSeal)
4,5,8,9,13
The ProSeal LMA is the most complex of the
specialized laryngeal mask devices. It was designed by
Archie Brain in the late 1990s and released in 2000. The
primary design goal was to construct a laryngeal mask with
improved ventilatory characteristics that also offered
protection against regurgitation and gastric insufflation. The
principal new features are a modified cuff and a drain tube.
The ProSeal LMA is a double mask, forming two end-to-
end junctions: one with the respiratory tract and the other
with the gastrointestinal tract.
Concept and Design
8,9,13
The ProSeal LMA is made from medical-grade
silicone and is reusable. The mask and inflation lines are
identical to the Classic LMA. The cuff has identical
proportions but different dimensions among sizes. The larger
ventral cuff is attached to a second cuff placed on the
dorsal surface of the bowl.
Mask design is also unique. The bowl is deeper and
has no aperture bars and the inflatable portion extends
around the back. When inflated, the mask is pushed
anteriorly and the glottis becomes enveloped in the bowl,
in contrast to the original design, in which the LMA and
the glottis opposed each other and the aperture bars prevented
the glottis from herniating into the bowl. There is a flexible
wire reinforced airway tube, and because of their concern
for gastric distention with positive pressure ventilation,
ProSeal has an integral gastric access/venting port and a
tube which traverses through the PLMA bowl. When properly
positioned, the distal orifice of this drain tube lies in the
upper esophagus. Sealed off from the glottis, the esophagus
and stomach can be vented to air or a 14-F sump tube can
be passed through the drain tube and gastric contents
evacuated. There is a plastic supporting ring around the
distal drain tube to prevent the drain tube collapsing when
the cuff is inflated.
A drain tube distal aperture that slopes anteriorly
allows the deflated tip to form a fine leading edge for
Fig. 4 : LMA C Trach
Fig. 5 : Disposable LMA
Fig. 7 : ProSeal LMA
SOOD : LMA VARIANTS 279
insertion. A rectangular depression in the proximal bowl
functions as accessory ventilation channel tube. A built-in
bite block helps to fuse the airway and drain tubes together,
prevents airway obstruction and damage to the device during
biting and provides information about depth of insertion.
The introducer tool is a reusable clip-on/clip-off
device that comprises a thin, curved, malleable, metal blade
with a guiding handle. Its inner surface and curved tip are
coated with a thin layer of transparent silicone to reduce
the risk of trauma. The distal end fits into the locating
strap, and the proximal end clips into the airway tube
above the bite block, with the proximal drain tube resting
to one side.
The locating strap (insertion strap) keeps the proximal
cuff in the midline, provides an insertion slot for the
introducer tool and also prevents the finger slipping off the
tube during insertion.
It is currently available in six sizes: 1.5, 2, 2.5, 3,
4 and 5. Size selection is similar to the Classic LMA and
can be either weight based (size 3 for adults and children,
30-50 kg; size 4 for normal adults, 50-70 kg; and size 5 for
large adults, 70-100 kg) or gender based (size 4 for female
patients; size 5 for male patients).
Anatomy
9,13
The anatomic position occupied by the ProSeal LMA
is similar to but more extensive than the Classic LMA. It
forms a seal with and provides a conduit to the respiratory
and gastrointestinal tracts. The larger, conical shaped distal
cuff fills the hypopharynx more completely, and the larger
wedge shaped proximal cuff fills the proximal laryngopharynx
more completely, both to form a better seal with their
respective tracts. The dorsal cuff may press the ventral
cuff more firmly into the periglottic tissues and the parallel,
narrower tubing may allow the base of the tongue to cover
the proximal cuff more effectively, enhancing its
effectiveness as a plug in the proximal pharynx. The internal
diameter of the ProSeal LMA airway tube is smaller than
the Classic and Intubating LMA airway tubes, making it
less suitable for passing instruments into the respiratory tract.
Indications
Indications are similar to the Classic LMA, but the
ProSeal is preferable whenever a better seal, better airway
protection, and access to the gastrointestinal tract are
required. It may be a better alternative for any elective
surgery where Classic LMA is used with controlled
ventilation and also for cardiopulmonary resuscitation.
13,14
Contraindications
Patients at risk of aspiration before induction of
anaesthesia.
8,13
Insertion
The principles of ProSeal LMA insertion are similar
to the Classic LMA. The semiflexible double tube is too
floppy to push the cuff around the oropharyngeal inlet into
the laryngopharynx but sufficiently stiff to push it into the
hypopharynx once it has entered the laryngopharynx. The
lack of a backplate makes the cuff more likely to fold over.
The bulkier deflated cuff reduces the space in the mouth for
digital manipulation and makes epiglottic downfolding more
likely.
8,13
Insertion techniques
There are three primary insertion techniques for the
ProSeal LMA: 1) digital insertion, which is similar to the
Classic LMA, but a lateral approach is required more
frequently; 2) introducer-guided insertion, which allows the
ProSeal to be inserted like the intubating LMA, but the
head and neck are in the sniffing rather than the neutral
position; and 3) gum elastic bougie guided insertion, which
guides the ProSeal around the oropharyngeal inlet and into
the hypopharynx.
8,9,13
Cuff inflation and fixation
The cuff volume required to form an effective seal
with the respiratory tract is lower for the ProSeal than the
Classic LMA. The cuff should be inflated with at least
25% of the maximum recommended volume to ensure an
effective seal with the gastrointestinal tract for prevention
of aspiration and gastric insufflation. A properly placed
PLMA can withstand peak inflation pressure of approximately
35 cms H
2
O without leak as compared to 25 cms H
2
O
offered by the LMA Classic.
8,13
Signs of correct ProSeal placement
8,13
a. Correct position of bite block
b. Chest expansion and capnograph
c. Seal pressure > 20 cms H
2
O
d. Gel displacement test - a blob (1ml) of water soluble
lubricant jelly is placed over the proximal opening of
the proSeal drain tube. Ejection of the gel from the
drain tube on gentle inflation of the bag indicates
presence of leak.
e. Gastric tube placement
f. Fibreoptic examination
Malposition is easily recognised and corrected. Common
malpositions are distal cuff in the laryngopharynx, glottic
inlet or folded over, glottic compression or epiglottic
downfolding (incidence 5 to 15%).
8,13
Emergence technique
Suction and remove the gastric tube, and reverse
any neuromuscular blockade before beginning emergence.
INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005 280 PG ISSUE : AIRWAY MANAGEMENT
Like the Classic LMA, remove when the patient obeys
commands.
8,13
Physiology
The upper esophageal sphincter function is relatively
unimpaired. The drain tube provides easy access to the
gastrointestinal tract for monitoring of cardiac output, gastric
volume / pH and core temperature. Cardiovascular responses
and peak airway pressures are similar to the Classic LMA
and are unaffected by cuff volume or tidal volume.
8,13
Caution
The ferromagnetic material present in LMAs can
reduce image quality and even cause heating and
movement when used in MRI.
8
N
2
O rapidly diffuses into the air filled cuff, causing
a doubling of intra cuff pressure within 1-2 hours.
8
Sterilization
The LMAs and their accessories are supplied
unsterile, and must be cleaned by hand washing or automatic
washers and autoclaved at 135C for 3-4 minutes
(pre-vacuum and wrapped). The cuff should be fully
deflated and dry before autoclaving. ProSeal requires more
attention. A small pipe cleaner should be used to clean the
drain tube and deflation of the ProSeal cuff requires the
deflation tool since residual air can accumulate in the
dorsal cuff.
7,8
Conclusion
Classic LMA along with its variants, flexible LMA,
ILMA, disposable LMA and ProSeal are now indispensable
in the armamentarium of airway management devices.
References
1. Brimacombe JR., Berry AM. The Laryngeal Mask Airway. In: The
Difficult Airway I. Anesthesiol Clin N Am June 1995; 13(2): 411-37.
2. Rasanen J. The laryngeal mask airway First class on Difficult Airways.
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3. Pollard BJ, Norton ML. Principles of Airway Management, In: Wylie
and Churchill Davidsons (ed), A Practice of Anesthesia (7
th
Edn),
2003; 28: 445-46.
4. Rosenblatt WH. Airway Management. In: Barash PG, Cullen BF,
Stoelting RK. (eds) Clinical Anesthesia (4
th
Edn) 2001; 23: 599-605.
5. Bogetz MS. Using the laryngeal mask airway to manage the difficult
airway. In: The Upper Airway and Anesthesia. Anesthesiol Clin N Am
Dec. 2002; 20(4): 863-70.
6. Verghese C, Brimacombe JR. Survey of laryngeal mask airway
Usage in 11, 910 patients: Safety and efficacy for conventional and
nonconventional usage. Anesth Analg 1996; 82: 129-33.
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th
Edn), Williams and Wilkins 1999; 15: 463-504.
8. Brimacombe JR. In: Laryngeal Mask Anesthesia - Principles and Practice
(2
nd
Edn), Saunders, Philadelphia 2005.
9. Khan RM(ed). Supraglottic airway devices. In: Airway Management
Made Easy. A manual for Clinical Practitioners and Examinees. Paras
Medical Publishers, Hyderabad, 2005; 12: 82-95.
10. Ovassapian A, Meyer RM. Airway Management. In: Longnecker DE,
Tinker JH (eds) Principles and Practice of Anesthesiology (2
nd
Edn),
Mosby : Philadelphia, 1998; 49: 1076-78.
11. McNicol LR. Insertion of the laryngeal mask airway in children.
Anaesthesia 1991; 46: 330.
12. http://www.LMACO.com. Instruction manual for LMA.
13. Brimacombe J, Keller C. The ProSeal laryngeal mask airway. In: The
Upper Airway and Anesthesia. Anesthesiol Clin N Am Dec. 2002; 20:
871-91.
14. Sharma B, Sahai C, Bhattacharya A, Kumra VP. Our experience with
ProSeal Laryngeal Mask Airway : A study of 200 consecutive patients.
J Anaesth Clin Pharmacol 2004; 20(1): 51-57.
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