Laryngeal Mask

Is it the best supraglottic airway?
4/27/2010 Otolaryngology online drtbalu

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Laryngeal mask airway
Dr. T. Balasubramanian M.S. D.L.O.

Introduction: Laryngeal mask was developed in 1980's, and recently is being used extensively in emergency medicine. It affords excellent ventilation without going through the normal intubation process and visualization of laryngeal inlet. It should be considered as a supraglottic airway management device. It can be introduced even by an emergency technician with training during emergency situations. Visualization of glottis is not essential for introduction of laryngeal mask airway. Laryngeal mask was first developed by a British Anesthesiologist by name Archie Brain in 1980. Brain considered laryngeal mask airway as a physical junction between artificial and anatomic airway. According to Brain the major advantages of Laryngeal mask airway are: 1. It reduced dead space 2. Allowed normal functioning of protective reflex 3. It was highly reliable than face mask ventilation 4. It is really helpful in managing difficult airway 5. It is very useful during failed endotracheal tube intubation when the abdomen is full of inflated air. In these patients the danger of aspiration is very real. Insertion of laryngeal mask airway will not only secure the airway in these patients but also prevent aspiration of stomach contents. 6. It can be introduced even without paralyzing the patient Development of laryngeal mask: Brain designed laryngeal mask after careful study of plaster casts of cadaver airway. He also conceived that by inflating an elliptical cuff at the level of hypopharynx an airtight seal could be achieved. This method required reliable avoidance of down-folding of epiglottis within the mask orifice during insertion. Laryngeal mask became commercially available in Britain in 1988, and US adopted it since 1992. Structure of laryngeal mask: Laryngeal mask currently available is made of medical grade silicone rubber. It is commonly available in 8 different sizes and cuff dimensions. 4 cc cuff volume is preferred in neonates and 50 cc cuff volume is used in large adults. Basically laryngeal mask consists of curve tubing, topped at the outer end by a standard 22 mm airway connector, and the inner end has an elliptical inflatable mask. Inside the lumen of the ellipse there are vertical elastic bars (concave) to control epiglottis after insertion. Laryngeal mask versions: Currently there are four versions of laryngeal masks available: 1. 2. Standard: This is autoclavable, reusable and can be used in operation theater settings. Single use disposable laryngeal mask: Useful in adults and children over 30 Kg. This is

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3 useful in emergency ward situations 3. Intubating laryngeal mask: This is suitable for blind intubation. 4. Flexible laryngeal mask: This tube is flexible and reinforced and is designed for use in head and neck surgical procedures

Picture showing laryngeal mask Procedure for inserting laryngeal mask: Step I: Selection of appropriate size mask. This is the first and rather important step. 1. 2. 3. 4. 5. 6. 7. Infants up to 5 kg – use 4 cc cuff Infants between to 5 – 10 kg – use 7 cc cuff Infants / children between 10 – 20 kg – use 10 cc cuff Children between 30 – 50 kg – use 20 cc cuff Adults between 50 – 70 kg – use 30 cc cuff Adults between 70 – 100 kg – use 40 cc cuff Adults over 100 kg – use 50 cc cuff

Step II: Preinsertion verification: In this step the laryngeal mask should be inspected for tight fit of its connector end. Tube itself is checked for cracks and presence of foreign bodies. The vertical bars over the aperture should be checked for flexibility and suppleness. It is this bar that prevents infolding of epiglottis into the laryngeal mask airway occluding it. The elliptical cuff is inflated and checked for the presence of leaks. Step III: Premedication and preoxygenation. www.drtbalu.com

4 In this step airway reflexes are blunted by giving appropriate drugs. Commonly used induction agent is Propofol in doses of 2.5mg / kg. Other drugs like thiopental in doses of 4mg /kg or a combination of midazolam 0.1 mg/kg with thiopental 5mg/kg have been equally effective. Oxygenation is maintained using mask airway. Step IV: Lubrication of laryngeal mask. In this step the elliptical cuff is fully deflated. Newmann suggested that partial inflation of the elliptical cuff will facilitate easier insertion. Oneill in his study also endorses the view held by Newmann. Posterior surface of laryngeal mask alone is lubricated using paraffin soaked gauze. It is better to avoid lubricants containing xylocaine as this would blunt the reflexes. Step V: Positioning the patient. In this step the patient is positioned appropriately for intubation. The neck of the patient is flexed and the head is moved into sniffing position. During this stage it is better to support the patient's head with the non dominant hand. The laryngeal mask airway is held in the dominant hand. The basic aim in positioning the patient is to provide at least 90 degree angle at the back of the tongue. Step VI: Insertion When exactly is it safe to perform the insertion? Whether the patient is sufficiently under? These are some of the dilemma faced by anesthesiologists before inserting laryngeal mask airway. It is for this purpose that the depth of anesthesia should be assessed. Depth of anesthesia can be assessed by: 1. Jaw relaxation 2. Loss of verbal contact 3. Eye lash reflex 4. Trapezius squeezing – This is a more accurate index to assess the depth of anesthesia before intubation. In this procedure the trapezius muscle is squeezed and any motor response is observed. Lack of motor response indicates that the patient is sufficiently anesthetized and is ready for intubation. The laryngeal mask is held in the non dominant hand like a pen. It is usually held at the junction of the tube and ellipse. The mask is pushed firmly against the hard palate with the index finger under direct vision. It is further advanced into the pharynx while staying above the tongue. The mask is then pushed further into the posterior pharyngeal wall. The mask usually follows the path of a food bolus during normal swallowing. Step VII: Inflation and seating of laryngeal mask. When the tip of the mask reaches the base of hypopharynx resistance is felt. It is precisely at this point the mask should be inflated. Accurate positioning can be confirmed by observing bag movements or by end tidal carbon dioxide levels. Indicators for proper positioning of the laryngeal mask: 1. 2. Bag movement End tidal carbon dioxide levels

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5 3. 4. 5. 6. Ability to generate an airway pressure of 20 cm of water without leak The ability to ventilate manually Ensuring that the black line on the laryngeal mask tube is in the patient's midline The laryngeal mask expansion can be palpated in the neck

When the tube is positioned correctly the cuff should seat in the hypopharynx at the interface between the air and food channels. The oesophagus and epiglottis are outside the rim of the elliptical mask. The laryngeal opening should be totally within the mask. The tube should be secured properly and bite block should be placed if necessary. At this juncture it should be pointed out that once positioned properly lesser dose of anesthetic medicine is required as the patient tolerates the tube well. Application of cricoid pressure: This topic is highly controversial. There are numerous theories that suggest that cricoid pressure will facilitate laryngeal mask intubation. There are also some papers which point out that cricoid pressure increases the difficulty of placement of laryngeal mask. The theory behind the technique of cricoid pressure runs like this: The tip of the laryngeal mask airway rests behind the cricoid cartilage after successful intubation.

Advantages of laryngeal mask airway in difficult / failed intubation are: 1. 2. 3. 4. Direct visualization of vocal cords while intubating with laryngeal mask is not necessary Neuromuscular blockade is not necessary, diminished airway reflexes suffice. Laryngeal mask airway can be used alone or as an aid to endotracheal intubation It can be used as an conduit for aerosol drugs into the lungs (epinephrine, albuterol etc)

Intubating laryngeal mask airway: Brain modified his originally designed laryngeal mask airway exclusively for the purpose of facilitating endotracheal intubation guided by laryngeal mask. This device not only served as a conduit for intubation but also maintained ventilation.

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Figure showing intubating laryngeal mask

Features of intubating laryngeal mask are: 1. Short anatomically curved rigid stainless steel shaft that follows the curvature of oral cavity, pharyngeal and laryngeal axis of the airway 2. A metal handle that aids the insertion and manipulation of the laryngeal mask 3. V shaped ramp that guides the endotracheal tube through the mask aperture directly into the glottis 4. A movable but rigid epiglottis elevating bar that lifts the epiglottis away from the advancing endotracheal tube

Image showing parts of ventilating laryngeal mask airway Insertion of intubating laryngeal mask is slightly different from that of laryngeal mask airway. 1. Selecting appropriate sized laryngeal mask airway. Usually intubating laryngeal mask airway is available in three adult sizes only. Sizes 3, 4, and 5 are available. Most adults under 70 Kg can be managed with size 4. 2. Since this tube is reusable, the autoclaved tube should be inspected for cuts, tears and presence of foreign bodies. The inflatable cuff should be tested for leaks. www.drtbalu.com

7 3. Premedication to blunt airway reflexes and oxygenation. 4. After deflation of the cuff, the posterior portion of the laryngeal mask airway should be lubricated. 5. Patient position: The patient's head and neck should be in neutral position. 6. Insertion: The intubating laryngeal mask airway is held by its metal handle. The mask tip is positioned against the hard palate immediately posterior to the upper central incisors. The tip of the mask is slid back and forth in the hard palate to coat the whole of hard palate with the lubricant. The mask is then slid backwards following the curvature of the tube. The fingers of the non dominant hand should be used to open the mouth gently. The metal handle of the laryngeal mask airway should not be used as a leverage to open the mouth. The entire device is pushed downwards into place. When positioned properly the tube would be seen emerging out of the mouth, lying approximately parallel to the plane of the inner surface of the upper central incisors. Resistance is usually felt when the tip of the mask hitches against the base of the hypopharynx. The cuff is inflated now. Indicators for proper positioning of ventilating laryngeal mask airway: 1. 2. 3. The ability to generate airway pressure of 20 cm of water The ability to ventilate manually If the positive pressure tidal volume of 8cc/kg is readily supported

Passing endotracheal tube via the ventilating laryngeal mask airway: Ventilating laryngeal mask airway is usually accompanied by silicone wire reinforced endotracheal tubes of three sizes (7, 7.5 and 8mm). Appropriate sized endotracheal tube is lubricated and advanced into the intubating laryngeal mask airway. The tube is rotated back and forth for redistribution of the lubricant. The endotracheal tube should not be advanced beyond the 15 cm mark to ensure that the tip of the tube does not enter the mask aperture. If the tube can be pushed beyond the 15 cm mark without any resistance then it indicates that the epiglottis bar of the laryngeal mask has managed to lift the epiglottis out of the way and the tube is passing into the trachea. If resistance is encountered beyond the 15 cm mark then it indicates that there is an infolding of epiglottis, or lodging of the tip of endotracheal tube against the vestibule preventing the endotracheal tube from entering the trachea. If the tip of the endotracheal tube gets hitched against the vestibule then rotating the endotracheal tube will overcome the problem. If obstruction is caused by an in-folded epiglottis then the laryngeal mask air way is slightly withdrawn and repositioned and then intubation is attempted. It is also imperative that appropriate sized intubating laryngeal mask airway is used for this purpose. If the laryngeal mask chosen is too small then the epiglottis would be out of reach of the epiglottis bar and hence will not be elevated out of the way, if the tube chosen is too large the epiglottis bar will be trapped between the arytenoids. In either of these two scenarios endotracheal intubation via the laryngeal mask airway will prove to be a problem. After successful introduction of endotracheal tube via the ventilating laryngeal mask airway the endotracheal tube may be connected to the boyles apparatus retaining the laryngeal mask airway insitu. If a decision has been made to remove the laryngeal mask retaining endotracheal tube, then the cuff of the laryngeal mask airway should be deflated and should be removed taking care to stabilize the endotracheal tube. A stabilizing rod can be used for this purpose. Problems associated with ventilating laryngeal mask airway in difficult intubation scenario: www.drtbalu.com

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1. The internal diameter of ventilating mask airway tube is too small to accommodate a normal sized endotracheal tube 2. It is too long to ensure that the endotracheal tube will pass between the vocal folds, hence a little bit unwieldy 3. Removal of laryngeal mask airway may prove to be difficult after successful endotracheal intubation.

Contraindications of laryngeal mask airway: 1. 2. 3. 4. Mouth opening less than 1.5 cms Poor lung compliance Airway pressure of more than 20 cm of water Non fasting patients

Risk of aspiration when laryngeal mask airway is used: When in position the tip of laryngeal airway mask lies at the upper oesophageal sphincter, still it does not isolate completely the respiratory tract from the GI tract and hence does not reliably protect the lungs from gastric contents. This glottic seal is totally lost at peak airway pressures above 20 cms of water. According to literature the incidence of aspiration when laryngeal mask is used is 3 per 10,000.

Maneuvers that facilitate proper introduction of laryngeal mask: Three different types of maneuvers have been developed to ensure that laryngeal mask is introduced properly without any problems. They include: 1. 2. 3. Brain maneuver (Up down movement) Bailey maneuver Chandy maneuver

Brain maneuver (up down movement): This maneuver was conceived and popularized by Archibald Brain who invented the laryngeal mask airway. After introduction of laryngeal mask airway the cuff is inflated. The whole tube is moved up and down without deflating the cuff inside the oral cavity. This procedure helps in repositioning the in folded epiglottis. This maneuver should be performed when there is resistance in the bag while ventilating the patient. Bailey maneuver: Paul Bailey of London first popularized the exchange of endotracheal tube to a laryngeal mask towards the end of a long surgical procedure provided excellent airway till the patient recovered from anesthesia completely. Towards the end of the surgery, while the patient is still under deep anesthesia a laryngeal mask devise is inserted behind the endotracheal tube and its www.drtbalu.com

9 cuff inflated. The endotracheal tube is removed after deflating its cuff. It has been demonstrated that laryngeal mask airway when properly inserted provided a clear airway without desaturation, coughing and straining. Chandy maneuver: Was popularized by Chandy vergheese. He suggested this maneuver to increase the success rate of blind intubation using laryngeal mask airway. This maneuver has three sequential steps. Step I: The expiratory valve of the breathing circuit should be partially closed to ensure high positive pressure within the breathing circuit. Step II: The metal handle is used to rotate the tube both in the axial and coronal planes, till optimal ventilation with minimal leak is achieved. Step III: The handle of the laryngeal mask airway is used to life the tube away from the posterior pharyngeal wall. This ensures proper seating of the elliptical mask at the level of hypopharynx.

Laryngeal mask variants available for widespread use at present: There are at present four different variants of laryngeal masks available. They include: 1. 2. 3. 4. Laryngeal mask flexible Laryngeal mask Fastrach (specially designed for tracheal intubation) Single use laryngeal masks (laryngeal mask unique) Laryngeal mask with integrated gastric access and ventilating ports (LMA-PROSEAL)

Laryngeal mask flexible: Flexible laryngeal mask is ideal solution for shared airway procedures like ENT, Faciomaxillary surgeries where rigidity of airway devices can obscure surgical access. This laryngeal mask is highly flexible because of its wire reinforcement. This tube can bend without kinking and hence can be adjusted anytime during the surgical procedure without fear of cessation of air flow.

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Figure showing flexible laryngeal mask airway This tube is available in three sizes.

It is useful in: 1. Head and neck surgical procedures 2. Pediatric surgical procedures where the surgeon and anesthetist has to compete for the airway 3. Can also be used during emergencies to secure the airway

Benefits of flexible laryngeal mask airway: 1. The position of the airway tube can be changed during surgery for better visualization of surgical field without loss of seal 2. Wire reinforcement prevents kinking and dislodgement during surgery 3. It is available in both adult and pediatric sizes Laryngeal mask Fastrach: This is a specially designed laryngeal mask for tracheal intubation. This is a wire reinforced straight cuffed tube with a Murphy eye with a standard 15 mm connector. It tip is unique and molded making the passage through the vocal cords atraumatic. There are two versions of this tube. One is disposable and the other one is reusable (autoclavable). Indications: 1. 2. Used as a guide for intubating the trachea Can be used as an alternative to face mask for reliable ventilation of the airway

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Image showing Fastrach laryngeal mask

Caution: These are some of the cautions that should be exercised while using laryngeal mask Fastrach. 1. Should not be used if the airway tube / cuff is damaged 2. Only the posterior surface of the laryngeal mask airway should be lubricated 3. The metal handle should not be pushed upwards during insertion as it will cause the mask to press into the tongue 4. Undue force should not be used during insertion 5. While inflating the cuff care should be taken to ensure that the volume doesn't exceed the maximum permissible levels 6. Caution should be exercised while using in patients with unstable cervical spine. Cadaveric studies have shown that certain amount of cervical spine movement is possible during insertion of this device. 7. Laryngeal mask is capable of causing pressure oedema in the mucosa of pharynx, hence it is advisable to remove the mask after successful endotracheal intubation. If a decision has been taken to leave it in place then excessive movements of head and neck should be avoided as this will cause pharyngeal oedema leading to post operative throat pain and dysphagia. 8. It should always be borne in mind that when used alone this laryngeal mask is not capable of protecting the lower airway from aspiration 9. The reusable variety of laryngeal mask Fastrach is supplied in an unsterile condition and must be cleaned and sterilized before use. Autoclaving is the best method of sterilizing the tube. Chemical sterilization is prohibited as this would cause injury to the delicate mucosa of tracheal airway. 10. This airway should not be used if the epiglottis elevating bar is damaged

Laryngeal mask with integrated gastric access and ventilating ports (LMA-PROSEAL): This is designed to facilitate positive pressure ventilation with higher airway pressure. This cannot be achieved by normal laryngeal masks. It has a second posterior cuff and a deeper bowl to improve laryngeal seal. It also has a drainage tube for access to the oesophagus. Its airway is reinforced and narrower than the conventional laryngeal mask. Its tip is devoid of the semi rigid black plate a feature of conventional laryngeal masks.

Advantages of Proseal airway: www.drtbalu.com

12 1. Provides better seal and protection to the airway 2. Useful for positive pressure ventilation 3. The special introducer provided makes introduction that much easier 4. The drainage tube lies inside the upper esophageal sphincter reducing the chances of regurgitation of stomach contents into the lower airway. Incorrectly placed Proseal mask will result in unreliable / obstructed ventilation. Only the correct placement of Proseal mask will produce leak free seal around the glottis with the mask tip and drainage tube lying inside the upper oesophageal sphincter.

Image showing Proseal laryngeal mask How to ensure that the proseal mask is correctly positioned? 1. Good chest movements 2. Caponograph 3. Airway leak pressure should be more than 20 cms of water 4. Soap bubble test: A thin film of non toxic soapy film is used to cover the drainage tube. The effect on changes to this film is observed. Normally the gel film doesn't move with positive pressure ventilation, or to brief firm pressure applied to sternum. It also does not move when the air pressure is raised to 20 cms of water. Technique of introduction of Proseal laryngeal mask is slightly different from that of normal laryngeal mask airway. It is also more demanding. It also needs higher doses of premedication. Three techniques have been popularized: 1. 2. 3. Digital technique: using fingers Using the introducer provided for this purpose Using Macintosh laryngoscope – This is the most invasive but a very reliable one

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