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Case Report

Classic Laryngeal Mask Airway Insertion with Laryngoscope

McGrath and Macintosh: A Case Series
Tjokorda Gde Agung Senapathi, Putu Agus Surya Panji, I Gede Herry Yudiskara, Adinda Putra Pradhana
Department of Anesthesiology, Pain Management, and Intensive Care, Udayana University, Sanglah General Hospital, Bali, Indonesia

Abstract
Laryngeal mask airway (LMA) is often performed for airway management. Correct placement of LMA can prevent severe leaks and even
obstruction of the airway. Insertion under laryngoscope guidance has been used to achieve the ideal positioning of the LMA. Efficacy of
LMA insertion by laryngoscope can be evaluated with cheap, safe, and easy to use method. This case series evaluates LMA insertion with
McGrath video laryngoscope and Macintosh laryngoscope. We use 20 cases to evaluate oropharyngeal leak pressure, time taken for insertion,
hemodynamic after insertion, first attempt insertion, ease of insertion, and adverse airway event after LMA insertion.

Keywords: Laryngeal mask, laryngoscope, leak pressure, McGrath, Macintosh

Introduction Case Report

The laryngeal mask airway (LMA) is a common supraglottic
device used to maintain the airway in patients undergoing
general anesthesia. [1] Although introduced and widely
used using a blind insertion approach, LMA can be
inserted using laryngoscopy to facilitate better anatomic
placement. [2‑6] Correct LMA position ensures proper
ventilation and minimizes airway adverse events during
insertion.[7‑10] Recently, oropharyngeal leak pressure (OPLP)
is used to evaluate airway protection after LMA insertion.[2]
On LMA insertion, laryngoscope keeps the tongue on the left
part of the oral caity, to bring the epiglottis into view.[2,3] The
advantage of using a video laryngoscope such as McGrath
for LMA insertion is the presence of a camera through a
blade that provides a wide‑angle view compared to a standard
laryngoscope blade.[2,4,5]
Twenty patients aged between 16 and 65  years old with
American Society of Anesthesiology physical status I–II who
underwent general anesthesia with LMA were enrolled in this
case series Table 1.
All of the patients received premedication with intravenous
midazolam 0.05 mg/kg BW. Patients were monitored using
standard monitoring. Anesthesia was induced using propofol
2  mg/kg and fentanyl 2  mcg/kg. After the patient lost
consciousness, 2 vol% sevoflurane was administered and
mask ventilation was performed for approximately 5 min for
adequate depth of anesthesia and muscle relaxation. Lubricated
LMA  (Teleflex™, Athlone Co. Westmeath, Ireland) was
inserted, and selection of the LMA size was based on the
bodyweight of the patient. LMA cuff was inflated at 60 cmH2O
using a handheld manometer. Anesthesia was then maintained
using compressed air, O2, sevoflurane, and fentanyl.

This case series was to assess the efficacy of classic LMA

insertion using McGrath video laryngoscope and Macintosh
laryngoscope. The primary outcome of this case series was the
OPLP measured by closing the expiratory valve of the circuit at
a fixed gas flow rate of 6 L/min and noting the airway pressure
at which the gas leaked into the mouth. The primary outcome
of this case series was the OPLP.
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Address for correspondence: Dr. Tjokorda Gde Agung Senapathi,
Department of Anesthesiology and Intensive Care, Faculty of Medicine,
Udayana University, Jl. PB Sudirman, Denpasar 80232, Bali, Indonesia.
E‑mail: tjoksenapathi@unud.ac.id
Submitted: 06‑Apr‑2020 Revised: 05-May-2020
Accepted: 15-May-2020 Published: 23-Jul-2020
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
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For reprints contact: reprints@medknow.com

How to cite this article: Agung Senapathi TG, Surya Panji PA,
DOI: Herry Yudiskara IG, Pradhana AP. Classic laryngeal mask airway insertion
10.4103/BJOA.BJOA_40_20 with laryngoscope mcgrath and macintosh: A case series. Bali J Anaesthesiol
2020;4:S64-6.

S64 © 2020 Bali Journal of Anesthesiology | Published by Wolters Kluwer - Medknow

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Senapathi, et al.: Classic laryngeal mask airway insertion with laryngoscope McGrath and Macintosh: A case series

Table 1: Evaluation of classic laryngeal mask airway insertion using McGrath video laryngoscope and Macintosh
laryngoscope
Subject A LMA insertion with McGrath (A) Subject B LMA insertion with Macintosh (B)
OPLP Time ∆HR ∆MAP Ease OPLP Time ∆HR ∆MAP Ease
(cm H2O) (s) (x/mnt) (mmHg) (cm H2O) (s) (x/mnt) (mmHg)
1A 22 30 10 19.0 F 1B 22 41 15 8.3 F
2A 24 32 10 2.0 F 2B 20 32 23 9.0 F
3A 26 34 12 5.0 F 3B 18 32 14 3.7 F
4A 26 35 15 7.7 F 4B 24 38 21 8.7 F
5A 26 34 11 3.3 F 5B 22 42 22 15.3 D
6A 20 32 10 10.0 F 6B 26 36 20 14.3 F
7A 20 36 22 12.7 F 7B 20 38 20 13.3 D
8A 22 37 18 7.0 F 8B 22 34 22 13.0 F
9A 24 33 24 11.7 F 9B 24 32 10 11.0 F
10A 26 39 26 13.7 F 10B 26 33 20 8.3 F
OPLP: Oropharyngeal leak pressure, Time: Time for LMA insertion, ∆HR: Heart rate 1 min after induction − heart rate 1 min after LMA
insertion, ∆MAP: Mean arterial pressure 1 min after induction − mean arterial pressure 1 min after LMA insertion, E: Easy, F: Fair,
D: Difficult, LMA: Laryngeal mask airway

Hemodynamic parameters were recorded at baseline, 1 min was 20–26 mmHg and with Macintosh 18–26 mmHg. Kim
after induction, and 1 min after insertion of the LMA. The et al. and Ozgul et al. reported that the OPLP was higher in the
OPLP was measured using a calibrated aneroid manometer laryngoscope‑guided LMA insertion.[2,4] Video laryngoscope
attached to the proximal end of the LMA. After closing the may improve LMA insertion conditions and prevent airway
expiratory valve of the circuit at a fixed gas flow rate of gas leaks, airway obstruction, and impaired gas exchange.[4]
6 L/min, OPLP was detected by audible air leak noise that
Video laryngoscope provides faster glottis visualization and
could be heard over the mouth and manometric stability.
reduced intubation time than direct laryngoscope.[13] Compared
To ensure safety, the maximal allowable OPLP was fixed
to blind insertion, laryngoscope guided has a longer time on
at 30 cmH2O. Time taken for LMA insertion is defined as
LMA insertion.[2,4] A systematic review by Lewis et al. found
the duration from the time the anesthesiologist picked up
that the proportion of successful first-attempt intubation was
the LMA till the ventilator tubing corrugated attached.
better on video laryngoscope.[14] Repeated attempts at inserting
Ease of LMA insertion is a subjective assessment of the
LMA increases the probability of airway trauma.[4] We found
insertion procedure by grading it as easy, fair, or difficult.
that classic LMA insertion time with McGrath was 30–39 s
Sore throat and blood on LMA after removal were evaluated
and with Macintosh 32–42 s. All of LMA insertion taken by
as an adverse event.
the first attempt and no adverse airway event were recorded.
In term of ease at insertion, all anesthesia residents who
There were no differences in hemodynamic parameters
inserted the LMA with McGrath gave fair opinion, but they
on blind LMA insertion and laryngoscope‑guided LMA
gave difficult to fair opinion on using Macintosh. All LMAs
insertion.[2,4] Yokose et  al. on a retrospective study found
were inserted by the first attempt. There was no adverse
that using a McGrath laryngoscope reduces the incidence of
airway event on our case such as sore throat and blood on
hypertension after tracheal intubation compared to a Macintosh
LMA.
laryngoscope.[15] In our case, the patient’s heart rate change
1  min after induction to 1  min after LMA insertion was
Discussion 10–26 beats/min with McGrath and 10–23 beats/min with
The correct LMA position will fit against the epiglottic tissues, Macintosh. Patients’ MAP change 1  min after induction to
occupying the hypopharyngeal space and upper esophagus, 1 min after LMA insertion was 2.0–19.0 mmHg with McGrath
forming a seal above the glottis instead of within the trachea.[7] and 3.7–15.3 mmHg with Macintosh.
Fber-optic use to evaluate LMA insertion provides conflicting
The ease of LMA insertion is very subjective and depends on
results. Ssome researchers suggested that fiber-optic score
experience using a laryngoscope for inserting the LMA. We
is not an accurate test to assess the seal of LMA.[10,11] It was
found that two residents experienced difficulty with LMA
suggested that the actual tightness of the inserted LMA rather
insertion using Macintosh laryngoscope, but others gave fair
than fiber‑optic view was an important parameter of adequate
comment.
airway management.[2,12] With OPLP values, we can evaluate
the quantity of airway seal and it is regarded as the most
important value for LMA feasibility of positive pressure Conclusion
ventilation.[2,4] In this case, we found that OPLP with McGrath Using video laryngoscope as an adjunct in LMA insertion

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Senapathi, et al.: Classic laryngeal mask airway insertion with laryngoscope McGrath and Macintosh: A case series
is helpful. Further studies with larger subjects to assess its
effectivity is needed in the future.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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