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Laryngeal Mask Airway in Medical Emergencies

Geoffrey Lighthall, M.D., Ph.D., T. Kyle Harrison, M.D., and Larry F. Chu, M.D.
The following text summarizes information provided in the video. Overview

During cardiopulmonary resuscitation (CPR), ventilation and chest compressions must be provided in a proper manner to be effective. Traditionally, ventilation is established through bag-and-mask ventilation, which is followed by endotracheal intubation with a cuffed endotracheal tube. However, because the level of skill required for successful placement of an endotracheal tube is high, only health care providers with experience in advanced airway-placement techniques should perform this procedure.1 The laryngeal mask airway (often referred to as LMA) is an alternative airway device that is both efficacious and relatively easy to place, even by novices. It is routinely used for patients who are under general anesthesia, since it provides a patent airway for patients who are breathing spontaneously and for those who are receiving mechanical ventilation. The laryngeal mask airway has been successfully used as an airway device for patients in cardiac arrest, even by personnel with little experience in airway management.2-6 The video provides basic instruction for medical personnel in the placement of a laryngeal mask airway as an alternative to endotracheal intubation in patients receiving cardiopulmonary resuscitation. The video also presents the rationale for using the laryngeal mask airway rather than bag-and-mask ventilation during CPR.
Indications

From the Palo Alto Veterans Affairs Hospital, Palo Alto (G.L., T.K.H.), and the Stanford University School of Medicine, Stanford (G.L., T.K.H., L.F.C) both in California. Address reprint requests to Dr. Lighthall at Palo Alto Veterans Affairs Hospital, Department of Anesthesia, 3801 Miranda Ave., Palo Alto, CA 94304, or at geoffl@stanford.edu.
N Engl J Med 2013;369:e26 DOI: 10.1056/NEJMvcm0909669
Copyright 2013 Massachusetts Medical Society.

The laryngeal mask airway is useful for the ventilation of patients in cardiac arrest, both before and after their arrival at the hospital. It has been recommended by the American Heart Association and the European Resuscitation Council as an acceptable device for use by nonexperts in endotracheal intubation when performing emergency airway management.7,8 The laryngeal mask airway can be used as an alternative to traditional bag-and-mask ventilation and is particularly useful when there is a need for prolonged resuscitation, when the personnel present do not have the competence to perform endotracheal intubation, when tracheal intubation cannot be performed or has failed, and when movement of the head and neck may injure the patient (e.g., in patients with injury to the cervical spine and in those with rheumatoid arthritis).9 However, the laryngeal mask airway is not considered a definitive airway and must be replaced with an endotracheal tube by a skilled provider of airway management at an appropriate time after resuscitation. There are very few contraindications to the placement of a laryngeal mask airway in patients in need of cardiopulmonary resuscitation, since the benefits of placement typically outweigh the risks.2,4,10 The risk of aspiration is always a concern because the device does not completely protect the patients airway from regurgitated gastric contents. However, the risk of gastric insufflation and pulmonary
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The new england journal of medicine

aspiration is lower with the use of a laryngeal mask airway than it is with bagand-mask ventilation.11 Some variants of the laryngeal mask airway have a suction port for gastric decompression that may decrease the risk of aspiration, but these variants have not been studied in patients during cardiac arrest. The placement of a laryngeal mask airway in patients with a limited mouth opening can be difficult or impossible to perform. The device should not be used in patients with a pharyngeal condition such as retropharyngeal abscess or hematoma. Reduced lung compliance or elevated airway resistance may necessitate the use of high inspiratory airway pressures that may lead to gastric insufflation, increasing the risk of aspiration. Finally, the presence of lesions below the glottis may cause obstruction of the airway that cannot be overcome with use of a laryngeal mask airway.12
Equipment and Anatomy

Figure 1. Types of Commonly Used Laryngeal Mask Airways.

Table 1. Recommended Size of the Laryngeal Mask Airway According to the Patients Body Weight. Size 1 1.5 2 2.5 3 4 5 Patients Weight <5 kg 59 kg 1019 kg 2029 kg 3049 kg 5069 kg Large adult, 70100 kg

All laryngeal mask airways contain an inflatable cuff, a connecting tube, a standard connector, and a tube for cuff inflation. Currently available laryngeal mask airways have either precurved or straight tubes and are designed for either a single use or multiple uses (Fig. 1). Some devices have a separate channel for suctioning the stomach, and others are designed to facilitate orotracheal intubation after the laryngeal mask airway has been placed. The materials required for placement of the laryngeal mask airway include the device itself, in a size appropriate for the patients weight (Table 1), a syringe for inflating the airway cuff (preferably with just enough air to achieve an adequate seal usually 20 to 40 ml for an adult-sized laryngeal mask airway), lubricating jelly, and plastic or cloth tape to secure the device. Often, single-use laryngeal mask airways come prepackaged with these supplies. A bag-and-valve mask device is required for the administration of positivepressure ventilation to the lungs through the laryngeal mask airway, and a stethoscope should be available to confirm breath sounds after placement of the device. It can be helpful to review the pharyngeal anatomy, including the tongue, hard palate, epiglottis, laryngeal inlet, and esophagus (Fig. 2), to better understand the proper placement of the laryngeal mask airway and to aid in troubleshooting.
Preparation of the Laryngeal Mask Airway

The laryngeal mask airway is prepared by lubricating the flat, posterior surface of the cuff. Most manufacturers recommend removing all air from the cuff before insertion. It is also important to make sure that all necessary supplies are present before insertion. Personal protective equipment, including gloves, eye protection, and a face mask, should be used if possible.
Placement of the Laryngeal Mask Airway

RETAKE AUTHOR Lighthall Anatomy. ICM 2. Figure Pharyngeal REG F CASE EMail Enon

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1st 2nd 3rd

With the patient in the supine position, stand behind the patients head. You may open the patients mouth with your hand, or you may gently tilt the head backward (Fig. 3). Exercise caution do not perform the backward head tilt in an unconscious patient who is suspected of having a neck injury.13 For placement of a straight laryngeal mask airway, grasp the tube with your dominant hand, with the curved portion of the tube and the flat side of the cuff facing the patient (Fig. 4). Successful insertion depends on keeping the leading edge flat at the time of insertion. Place your first finger in the space between the tube and the cuff. Using your first finger, direct the cuff upward against the hard palate (maintaining constant upward pressure of the cuff on the hard palate at all times during insertion), and then guide it above the tongue and down through the oropharynx in a smooth, continuous motion (Fig. 5). Continue the insertion until
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Laryngeal Mask Airway in Medical Emergencies

you encounter resistance, at which time 7 to 10 cm of the tube usually continues to protrude from the patients mouth. To place a precurved laryngeal mask airway, hold the connecting tube so that the flat side of the cuff is pointing toward the patient; your hand should be in a neutral position, with the thumb on the upward surface of the tube. As with the straight tube, the flat upward side of the cuff is inserted along the hard palate with the use of firm pressure. Guide the tube behind the tongue and toward the larynx using a circular motion of the wrist. Regardless of type of tube, placement should be accomplished with gentle pressure and without the use of force. Once the tube has been fully inserted, inflate the laryngeal balloon with approximately 30 ml of air (for adult-sized laryngeal mask airways). Do not hold the tube while the air is being introduced; during inflation, the laryngeal mask airway often slides out of the mouth by 1 to 2 cm as it settles into its proper location. The final resting position is posterior to the tongue, at the laryngeal inlet (Fig. 6). The cuff should not be visible when the tube is in its proper position. Connect the laryngeal mask airway to a positive-pressure ventilation system (an Ambu bag), verify placement through the auscultation of breath sounds, and secure the device with tape.
Troubleshooting

Figure 3. Positioning the Patients Head during Placement of the Laryngeal Mask Airway.

Failure to fully pass the laryngeal mask airway behind the base of the tongue is a common obstacle to successful placement. Anatomical challenges, such as pharyngeal swelling or large tonsils, can also make placement difficult. If the cuff folds on itself or gets caught on pharyngeal tissue, the device should be removed and reinserted with attention to proper alignment and the application of pressure on the hard palate. If placement is still difficult, additional attempts can be modified by adding a small amount of air (5 to 10 ml) to the cuff and by introducing the tube at an angle that is 30 to 45 degrees off the main axis. If air leaks are detected with gentle ventilation, add more air to the cuff through the connecting tube. If air continues to leak, remove and then reinsert the laryngeal mask airway. If the patients chest does not rise after reinsertion, try a different size and make another attempt at placement. Signs of adequate ventilation should be continuously monitored. Even when secured, the laryngeal mask airway may become dislodged with motions such as twisting or pulling. When moving a patient after placement, place one hand at the base of the laryngeal mask airway and disconnect the ventilation system from the device.
The Laryngeal Mask Airway in CPR

Figure 4. Grasping the Laryngeal Mask Airway. The airway should be grasped with the dominant hand, with the first finger positioned between the tube and the cuff.

Figure 5. Inserting the Laryngeal Mask Airway. The distal end, or cuff, of the device should be eased upward against the hard palate and then down into the oropharynx in a smooth, continuous motion.

The laryngeal mask airway can be placed rapidly during CPR with the techniques described. Auscultation of breath sounds should take less than 5 seconds. In general, placement of the laryngeal mask airway during resuscitation should not require interruption of chest compressions. While administering chest compressions in an adult, provide eight to ten 500-ml breaths per minute. The duration of the breaths should be less than 1 second each. If the chest compressions are causing most of the inflated air to leak from around the tube, alternate respirations and compressions, with two 500-ml breaths administered after every 30 chest compressions. This cycle of 30 compressions to two breaths should be continued for as long as CPR is being performed. Delivery of drugs through the laryngeal mask airway to the pulmonary epithelium is unreliable and is not recommended. The laryngeal mask airway may be left in place for the duration of the resuscitation. If an artificial airway is still needed, an experienced provider in airway management should be brought in to replace the laryngeal mask airway with a regular endotracheal tube.
n engl j med 369;20 nejm.org november 14, 2013

Figure 6. Establishing the Final Position of the Laryngeal Mask Airway. The device should reside posterior to the tongue at the laryngeal inlet. (The airway appears blue for the purposes of illustration).

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Laryngeal Mask Airway in Medical Emergencies

References 1. Nolan JD. Prehospital and resuscitative airway care: should the gold standard be reassessed? Curr Opin Crit Care 2001; 7:413-21. 2. Davies PR, Tighe SQ, Greenslade GL, Evans GH. Laryngeal mask airway and tracheal tube insertion by unskilled personnel. Lancet 1990;336:977-9. 3. Grantham H, Phillips G, Gilligan JE. The laryngeal mask in pre-hospital emergency care. Emerg Med 1994;6:193-7. 4. Kokkinis K. The use of the laryngeal mask airway in CPR. Resuscitation 1994; 27:9-12. 5. Reinhart DJ, Simmons G. Comparison of placement of the laryngeal mask airway with endotracheal tube by paramedics and respiratory therapists. Ann Emerg Med 1994;24:260-3. 6. 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; 1:123-5. 7. ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2005;112:Suppl:IV-1IV-203. 8. Nolan JP, Deakin CD, Soar J, Bttiger BW, Smith Gl. European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support. Resuscitation 2005;67:Suppl 1:S39-S86. 9. Foley LJ, Ochroch EA. Bridges to establish an emergency airway and alternate intubating techniques. Crit Care Clin 2000;16:429-44. 10. Pennant JH, Walker MB. Comparison of the endotracheal tube and laryngeal mask in airway management by paramedical personnel. Anesth Analg 1992; 74:531-4. 11. Stone BJ, Chantler PJ, Baskett PJ. The incidence of regurgitation during cardiopulmonary resuscitation: a comparison between the bag valve mask and laryngeal mask airway. Resuscitation 1998;38:3-6. 12. Kokkinis K, Papageorgiou E. Failure of the laryngeal mask airway (LMA) to ventilate patients with severe tracheal stenosis. Resuscitation 1995;30:21-2. 13. Pennant JH, Gajraj NM, Pace NA. Laryngeal mask airway in cervical spine injuries. Anesth Analg 1992;75:1074-5.
DOI: 10.1056/NEJMvcm0909669
Copyright 2013 Massachusetts Medical Society.

Complications

The complications associated with the use of a laryngeal mask airway are similar to those seen with other instruments used for airway management. However, in some situations, the risk of certain complications may be lower than when bag-andmask ventilation or endotracheal intubation is used. These complications include the potential for upper-airway trauma, tooth dislodgment or damage, and the introduction of air into the stomach.9 Despite its numerous advantages for rescue ventilation, the laryngeal mask airway does not provide a secure airway and will not protect against pulmonary aspiration when the volume of gastric contents is large or under pressure. It may be difficult to ventilate a patient with a laryngeal mask airway when airway or thoracic pressures are high (e.g., during active chest compressions, during placement in obese patients, and during placement in patients with lung parenchymal disease). Additional familiarity with the laryngeal mask airway can be gained with practice. A demonstration model or a patient simulator may be used, or practice can be obtained with real patients in the operating room under the guidance of an anesthesiologist.
Summary

The laryngeal mask airway is a fast and effective alternative to endotracheal intubation and is used for an increasing number of clinical indications, including ventilation during cardiopulmonary arrest. Placement of this device is usually successful on the first attempt; thus, it is an important procedure to learn and practice.
No potential conflict of interest relevant to this article was reported. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

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n engl j med 369;20nejm.orgnovember 14, 2013

The New England Journal of Medicine Downloaded from nejm.org on November 13, 2013. For personal use only. No other uses without permission. Copyright 2013 Massachusetts Medical Society. All rights reserved.