Technology, Computing and Simulation

E   SPECIAL ARTICLE

Supraglottic Airway Devices: Present State and

Outlook for 2050
André A. J. van Zundert, MD, PhD, MSc (Med), FHEA, FRCA, EDRA, FANZCA,*
Stephen P. Gatt, MD, MSc, FANZCA, FRCA, FCICM, FACHSM, AFRACMA,†‡
Tom C. R. V. van Zundert, MD, PhD, MSc, EDRA, FANZCA,§ Carin A. Hagberg, MD, FASA,∥ and
Jaideep J. Pandit, MA, BM, DPHIL, FRCA, DM¶

Correct placement of supraglottic airway devices (SGDs) is crucial for patient safety and of prime
concern of anesthesiologists who want to provide effective and efficient airway management
to their patients undergoing surgery or procedures requiring anesthesia care. In the majority of
cases, blind insertion of SGDs results in less-than-optimal anatomical and functional positioning
of the airway devices. Malpositioning can cause clinical malfunction and result in interference
with gas exchange, loss-of-airway, gastric inflation, and aspiration of gastric contents. A close
match is needed between the shape and profile of SGDs and the laryngeal inlet. An adequate
first seal (with the respiratory tract) and a good fit at the second seal of the distal cuff and the
gastrointestinal tract are most desirable. Vision-guided insertion techniques are ideal and should
be the way forward. This article recommends the use of third-generation vision-incorporated-
video SGDs, which allow for direct visualization of the insertion process, corrective maneuvers,
and, when necessary, insertion of a nasogastric tube (NGT) and/or endotracheal tube (ETT)
intubation. A videoscope embedded within the SGD allows a visual check of the glottis opening
and position of the epiglottis. This design affords the benefit of confirming and/or correcting a
SGD’s position in the midline and rotation in the sagittal plane. The first clinically available video

From the *Department of Anaesthesia and Perioperative Medicine, Royal
Brisbane and Women’s Hospital, & The University of Queensland, Brisbane,
Queensland, Australia; †Department of Anaesthesia, University of New South
Wales, Kensington, New South Wales, Australia; ‡Department of anaesthesia,
Udayana University, Bali, Indonesia; §Department of Emergency Medicine, Holy
Heart Hospital, Mol, Belgium; ∥Department of Anesthesiology & Perioperative
Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas; and
¶Department of Anaesthesia, University of Oxford, Oxford, United Kingdom.
Copyright © 2023 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000006673
Accepted for publication June 23, 2023.
Funding: None.
Conflicts of Interest: See Disclosures at the end of the article.
Reprints will not be available from the authors.
Address correspondence to André A. J. van Zundert, MD, PhD, MSc (Med),
FHEA, FRCA, EDRA, FANZCA, Professor and Chair of Anaesthesiology,
Department of Anaesthesia & Perioperative Medicine, Royal Brisbane &
Women’s Hospital, Ned Hanlon Bldg L4 - Herston Campus-Brisbane, QLD
4029, Australia. Address e-mail to a.vanzundert@uq.edu.au

February 2024 • Volume 138 • Number 2 www.anesthesia-analgesia.org 337

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 Vision-Guided Insertion of Supraglottic Airway Devices or Video Laryngeal Mask Airways

laryngeal mask airways (VLMAs) and multiple prototypes are being tested and used in anesthe-
sia. Existing VLMAs are still not perfect, and further improvements are recommended. Additional
modifications in multicamera technology, to obtain a panoramic view of the SGD sitting correctly
in the hypopharynx and to prove that correct sizes have been used, are in the process of produc-
tion. Ultimately, any device inserted orally—SGD, ETT, NGT, temperature probe, transesophageal
scope, neural integrity monitor (NIM) tubes—could benefit from correct vision-guided position-
ing. VLMAs also allow for automatic recording, which can be documented in clinical records of
patients, and could be valuable during teaching and research, with potential value in case of
legal defence (with an airway incident). If difficulties occur with the airway, documentation in the
patient’s file may help future anesthesiologists to better understand the real-time problems. Both
manufacturers and designers of SGDs may learn from optimally positioned SGDs to improve the
design of these airway devices. (Anesth Analg 2024;138:337–49)

GLOSSARY
ADEPT = Airway Device Evaluation Project Team; ASA = American Society of Anesthesiologists;
COVID-19 = coronavirus disease 2019; CT = computed tomography; ENT = ear, nose, and throat
surgery; ETT = endotracheal tube; LMA = laryngeal mask airway; MRI = magnetic resonance
imaging; NGT = nasogastric tube; NIM = neural integrity monitor; NMB = neuromuscular block-
ers; OPLP = oropharyngeal leak pressure; PUMA = Project for Universal Management of Airways;
PVC = polyvinyl chloride; SGD = supraglottic airway device; SLIPA = streamlined liner of the phar-
ynx airway; Spo2 = peripheral oxygen saturation; VLMA = video laryngeal mask airway; VLS =
videolaryngoscope

Design is not just what it looks like and feels like. Design is the curvature of the tongue), and complex technical
how it works. maneuvers may be required to secure the airway.
Steve Jobs (1955–2011), founder of Apple Inc Device placement often needs to be achieved by a
direct line-of-sight (eg, ETT using a Macintosh laryn-

T
his article emphasizes that the correct place-
ment of supraglottic airway devices (SGDs) is
as important as the proper positioning of endo-
tracheal tubes (ETTs) and that optimal SGD placement
and positioning is best facilitated by direct vision.
There are 3 challenges to overcome to achieve this
aim. One is technical: the early SGDs permitting direct
vision remain to be fully tested and are imperfect. The
second is intellectual: the persistent belief that surro-
gate end points, such as oropharyngeal leak pressure
(OPLP) or adequate lung ventilation, among others,
are sufficient to confirm correct placement. The third
is behavioral: the common practice to accept clearly
suboptimal placement (poor OPLP, noisy breathing,
abnormal end-tidal CO2 waveform) in the conduct of
anesthesia for surgery. We will address each of these
technical, intellectual, and behavioral issues, noting
of course that they are not independent. Behavioral
change can only occur after intellectual buy-in, which
often depends on their existing effective devices to
achieve the desired aim. Equally, behavioral and intel-
lectual drivers can be powerful to stimulate technical
advances.
Proper airway management is crucial for patients
and is a primary concern of anesthesiologists.
Insertion of both ETTs and SGDs needs to be effective
(whether it achieves the aim), safe (without compli-
cations), and efficient (how easily or quickly place-
ment is performed). This is not always easy because
the pathway of device insertion is not straight (due to
goscope) or using a “blind” insertion technique (eg,
SGD using standard methods). SGDs were introduced
to practice using blind techniques and have proved
reasonably effective, with the laryngeal mask airway
(LMA) and its variants—such as i-gel— being used
for a large number of indications, by both experienced
and inexperienced operators.
Although first-generation SGDs generally
achieved easy, atraumatic insertion with minimal
hemodynamic stimulus and high first-attempt suc-
cess with the ability to ventilate the lungs, additional
SGD uses and models evolved, notably the use of
the SGD as a conduit for insertion of a nasogastric
tube (NGT) or ETT1–6 or more ideally, incorporation
of videoscope technology.7,8 As SGDs were increas-
ingly used to facilitate positive-pressure lung venti-
lation, the need arose for high airway seal pressures
to protect the airway from gastric and other fluids
(secretions, blood, and pus). Other desirable charac-
teristics of SGDs include (a) easy, atraumatic inser-
tion with minimal hemodynamic stimulus; (b) high
first-attempt success with ability to ventilate the
lungs; (c) permit insertion of a NGT and/or an ETT
using the SGD as an insertion/intubation conduit;
and (d) high airway seal pressures protecting the air-
way from gastric and other fluids (secretions, blood,
a
LMA-ProSeal is a registered trademark of Teleflex Incorporated or its
affiliates.
b
LMA-Protector is a registered trademark of Teleflex Incorporated or its
affiliates.

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 E  SPECIAL ARTICLE  
and pus). Because of these multiple dimensions of
functionality, numerous SGDs have been introduced
and comparing their performance is challenging.
For this reason, the Difficult Airway Society in the
United Kingdom recommended a standardized, evi-
dence-based approach to clinical assessment (termed
Airway Device Evaluation Project Team [ADEPT]).9
The first formal trial under this program was recently
published,10 and moreover, updated recommenda-
tions (ADEPT-2) have been proposed.11
The performance of SGDs, which can range from
easy to problematic, depends on patient factors, the
anesthetic plan (including urgency of any interven-
tion) and the SGD design (including dimensions and
material). Some SGDs are bulkier than others. Still
others feature higher device conditioning stiffness
and friction coefficients, have a thicker cuff and/or a
higher cuff profile, for example, LMA®-ProSeal™,a,12
LMA®-Protector™,b,13 Baska-Mask,14 streamlined
liner of the pharynx airway (SLIPA).15 Therefore, use
of some SGDs requires more training,16,17 and addi-
tional adjunct devices may be necessary, such as, for
example, an introducer, a stylet, a gum elastic bougie,
a gastric tube,18–20 while others can be readily inserted
by novices.21,22 Some SGDs have a preshaped, anatom-
ically curved tube following the normal oropharynx
anatomy, or include a fixation tab.13
General difficulties encountered during “blind”
insertion have led some authorities to advocate using
the 90° rotational technique, a lightwand or a (video)
laryngoscope-assisted technique, a Frova-catheter-
based railroad technique, or gastric tube- or suction
catheter-driven insertion.23 The fact that there are so
many different designs of SGDs is proof that we still
do not have the ideal device. Even when these devices
are apparently easily placed, SGDs can be ineffective
in facilitating optimal gas exchange or protecting the
patient’s lungs.
In this context, we challenge the common cur-
rent practices concerning SGDs (namely that their
use continues even when poorly positioned; and
the erroneous belief that surrogate end points
confirm correct placement). Then we will address
some of the technical issues in designing vision-
guided SGDs. First, we will provide a historical
perspective.
c
LMA-Classic is a registered trademark of Teleflex Incorporated or its
affiliates.
d
LMA-Flexible is a registered trademark of Teleflex Incorporated or its
affiliates.
e
LMA-Unique is a registered trademark of Teleflex Incorporated or its
affiliates.
f
LMA-Supreme is a registered trademark of Teleflex Incorporated or its
affiliates.
g
LMA-Gastro is a registered trademark of Teleflex Incorporated or its
affiliates.
h
LMA-Fastrach is a registered trademark of Teleflex Incorporated or its
affiliates.
February 2024 • Volume 138 • Number 2
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HISTORICAL VIGNETTES: FROM THE CLASSIC LMA
TO VISION LMAs
For decades, airway management was performed by
using a handheld facemask and insertion of an ETT.
Archie Brain revolutionized airway management
with a brilliant idea based on the groundbreaking
concept of the LMA.1 It was the beginning of a large
family of SGDs, that is, LMA®-Classic™,c, LMA®-
Flexible™,d, LMA®-Unique™,e, LMA®-ProSeal™,
LMA®-Supreme™,f, LMA®-Protector™, and LMA®-
Gastro™,g (Figure 1),24 originally produced by The
Laryngeal Mask Company Ltd in the United Kingdom
and later by Teleflex.
Brain adopted an engineered approach to the prob-
lem and asked the question, “How do we naturally
get down an airway device to the level of the pharynx-
larynx?” And the answer is simple—it is how we eat.
After masticating the food by the teeth, the bolus of
food is formed into an oval shape by the tongue and
the hard palate, whereby the oval shape is directed
posteriorly and passes into the hypopharynx. The
upper esophageal sphincter then opens and the food
is carried down by peristalsis.25
Archie Brain made the first prototype himself,
tested it on cadavers, and used it on a patient in mid-
1981 at the William Harvey Hospital in Ashford.1
After sterilization in chloroform, the device was
inserted under deep halothane anesthesia, imme-
diately producing a clear airway, allowing gentle
manually assisted breathing of the lungs, forming an
effective seal with the glottic inlet. Surgery and anes-
thesia were entirely uneventful, and the patient had
no sore throat afterward. Greatly encouraged by this
first experience, many more prototypes would follow,
all produced by Brain himself. Brain conducted the
first clinical LMA study at the Royal London Hospital
in 1982. All 23 gynecological patients were successful,
with a 10-second average insertion time, airtight seal
>20 cm H2O and uneventful emergence. Soon, Brain
found that airway obstruction and leaks were the
most pressing problems; he detected that the tip of the
LMA cuff was dragging the epiglottis down during
insertion, which prompted him to create a string of
prototypes, each improving further de original device
(Figure 2). For years, there was a lack of commer-
cial interest from manufacturers but on December 5,
1987, Brain received the first case of all-factory-made
LMA®-Classics™. Others began to use LMAs clini-
cally, which exceeded their expectations, amusingly
advocating “Use your Brain.”
Many similar (reusable and disposable) versions
would follow, and the authors collected more than
130 different devices at this time (Figure 3A–C), span-
ning 3 generations of devices, that is, with a ventila-
tion channel only (first), with a ventilation channel
and gastric channel (second), and including video-
scope technology (third).
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 Vision-Guided Insertion of Supraglottic Airway Devices or Video Laryngeal Mask Airways

Figure 1. Dr Archie Brain’s LMA®-Classic™ was the groundbreaking concept for a whole family of Laryngeal Mask Airways, ie, LMA®-Classic™,
LMA®-Flexible™, LMA®-Unique™, LMA®-Fastrach™,h, LMA®-ProSeal™, and LMA®-Supreme™. Courtesy Dr Tom van Zundert.24

The LMA®-Classic™—a simple but brilliant idea—
has made the life of anesthesiologists much easier,
and the life of our patients, for whom we care, that
much safer.
BLINDLY INSERTED SGDs ARE OFTEN NOT
CORRECTLY POSITIONED
At present, the majority of SGDs are inserted using
“blind” placement. Brimacombe describes how best
to assess function and position of the LMA, testing
the efficacy of seal with the respiratory and gastro-
intestinal tract and the position of the tube. The cuff
is mostly hidden from view and its position must be
inferred from clinical indicators, or from instrumen-
tation, for example, fiberoptic scope, lightwand or
the esophageal detector device, while precise posi-
tion of the cuff can only be determined by medical
imaging techniques. Far too often, clinicians rely
on a range of subjective, indirect assessments and
“blind” clinical tests, to evaluate the correct place-
ment of SGDs. These observational tests include (a)
auscultation; (b) leakage test; (c) self-inflating bulb
technique; (d) Trachlight lightwand test; (e) gastric
insufflation test; (f) soap bubble/gaze thread drain
tube test; (g) suprasternal notch test; (h) gastric
tube test; and (i) maximum minute volume ventila-
tion test.7 Subjective evaluations are not sufficient
as proof of correct positioning. Even if all clinical
signs are reassuring (“normal” capnogram trace,
bilateral chest excursion, absence of an audible leak
at the mouth at peak inspiratory pressure of 20 cm
H2O), one cannot be certain that the “blind” inser-
tion has resulted in correct positioning. Even OPLP,
considered a measure of successful SGD placement
and acceptable performance, is based on the prem-
ise that the airway device is positioned properly in
the hypopharynx.26 Hundreds of scientific publica-
tions have used OPLP as a primary outcome indica-
tor for comparing safety and utility of various SGDs.
Unfortunately, OPLP measurements in an anatomi-
cally inadequately placed SGD can yield correct
values. Furthermore, OPLP is subject to variations,
depending on anesthesia technique, depth of anes-
thesia and using drugs, the use of neuromuscular
blockers (NMBs) both depolarizing and nondepo-
larizing, head position, cuff volume, choice of SGD
(first- or second-generation, material cuff, size),
third-generation direct-vision SGDs and anatomical
match and seal between the contour of SGD cuff and
pharynx-larynx complex.

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 E  SPECIAL ARTICLE  
This can yield acceptable clinical standards for
placement, but also is shown to result in 50% to 80%
of aberrant positioning within the oro/hypopharynx,
where the SGDs should rest.27,28 Numerous clinical
studies involving magnetic resonance imaging (MRI),
computed tomography (CT), lateral neck radiogra-
phy, and fiberoptic view demonstrated these aber-
rant positions, even when the anesthesiologist felt
after blind insertion that they were correctly sited.
Brimacombe described 7 well-recognized malposi-
tions: (1) epiglottic downfolding; (2) infolding of ary-
epiglottic folds; (3) rotation in the sagittal plane with
respect to the pharynx or larynx; (4) backward fold-
ing of the distal cuff; (5) glottis distortion; (6) distal;
as well as (7) proximal cuff misplacement. Any or
all these anatomical misplacements can still result in
clinical signs suggesting proper positioning.
Fiberoptic evaluation frequently reveals malposi-
tioning but does not in itself help to correct the posi-
tion. Furthermore, an audit on 306 blindly inserted
SGDs,29 revealed that an optimal position of SGD,30
was only obtained in 29% of the patients and 71% of
devices were malpositioned. The audit provided some
February 2024 • Volume 138 • Number 2
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Figure 2. Inventor Archie Brain of
the LMA®-Classic™ (first-genera-
tion supraglottic airway devices),
showing the first prototype of the
LMA®-ProSeal™ (second-genera-
tion supraglottic airway devices).
Courtesy Dr Archie Brain.
indications of incidences of malpositioning types, for
example, epiglottis downfolding (71%) or double-
folding (5%); use of incorrectly sized SGD (9%); cuff
folding-over backwards (1%) or distal cuff touching
the vocal cords (4%), and cuff distortion (91%) by fold-
ing of the polyvinyl chloride cuff material, causing
an air leak (8%).29 Figure 4 shows some examples of
anatomically malpositioned devices inserted blindly
with potentially substandard functional outcomes.
The tendency for malpositioning of the existing SGDs
may be a result of inappropriate design, incorrect siz-
ing, hypo- and hyperinflation of the cuff, or too deep
or too superficial insertion.25
The conclusions of these lines of research causes
us to distinguish between “functionally appropriate
placement” and “anatomically correct placement.”
When anatomically correctly placed, an SGD will
always fulfill the functional criteria for good place-
ment. If it does not, it implies lower airway problems
(eg, laryngeal spasm, bronchoconstriction, chest wall
rigidity, or pulmonary edema). In contrast, an SGD
that fulfills functional criteria but is, in fact, subopti-
mally placed carries the following risks. First, further
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 Vision-Guided Insertion of Supraglottic Airway Devices or Video Laryngeal Mask Airways
dislodgment could lead to clinical malfunction and,
therefore, loss of the airway (which might also include
aspiration of gastric contents if the esophageal seal
is poor). Second, any later difficulty with airway
patency or desaturation could lead to avoidable diag-
nostic dilemmas and misleading corrective actions
(eg, if it is assumed the SGD was initially properly
positioned, interventions may be misdirected at lower
airway issues such as bronchoconstriction, when the
true problem is later SGD malposition). Third, if the
patient is in, or enters, cardiac arrest, it is essential that
the SGD is both anatomically and clinically optimally
positioned.
We argue that these anatomical criteria, as opposed
to the clinical/physiological criteria, can only be met
by checking with direct vision, and we discuss options
for doing this below.
ANESTHESIOLOGISTS (MIS)USE POORLY PLACED
SGDs THAT DO NOT MEET EVEN CLINICAL
CRITERIA FOR PROPER PLACEMENT
It is our observation that even SGDs that do not ful-
fill clinical criteria for proper placement continue to
be used throughout surgery. Anecdotally, we have
all experienced taking over or relieving a colleague
for a break, whose patient is spontaneously breath-
ing via an SGD, with labored, partially obstructed
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Figure 3. Nonexhaustive list of
examples of (A) first-generation
supraglottic airway devices with
LMA®-Classic™ (center), sur-
rounded by similarly designed
cuffed airway devices (ventila-
tion channel only); (B) second-
generation supraglottic airway
devices with separate ventilation
and gastric channels, eg, air-Q
Blocker, LMA®-ProSeal™, LMA®-
Supreme™, Baska Mask, LMA®-
Protector™; (C) third-generation
supraglottic airway devices, eg,
SaCoVLM (left panel) and SafeLM
(right panel) video laryngeal mask
airways, combining a second-gen-
eration laryngeal mask and a vid-
eoscope inserted into the tube of
the laryngeal mask. These devices
come with a monitor screen and 3
orifices for channels (airway tube,
videoscope, and gastric drainage
channel); and a camera and light
source arising at bowl.
noisy breathing, or a clear leak, especially when
lung ventilation is supported with some positive or
triggered pressure. Earlier, Brimacombe31 described
13 strategies for solving problems of malfunction-
ing SGDs.
Fundamentally, most SGDs are very forgiving
devices and can still function when not optimally
placed. Even under suboptimal conditions, oxygen
saturation may be well maintained for prolonged
periods. We have previously graded the degree of
(mal)position (Table 1) and reported that grade I is
uncommon while grade II is more common, yet both
facilitate lung ventilation.30 The worst-case scenario is
grade III (which is characterized by severe gas leak-
age, malobstruction of the airway, abnormal/absent
capnogram, inadequate/no ventilation of the lungs,
and (very) low values for intracuff pressure, Spo2, and
OPLP). A grade III SGD is not compatible with effec-
tive lung ventilation.
Functional fit will result from providing: (a) 2 seals:
1 with the gastrointestinal tract and 1 with the respi-
ratory tract (sealing the glottic entrance, whereby the
glottis opening is opposing the distal opening of the
airway tube); (b) the esophageal seal acts as a func-
tional barrier from soiling the airways with secretions,
blood and pus, preventing gastric inflation and aspi-
ration; (c) adequate gas (oxygen, CO2 and other gases)
ANESTHESIA & ANALGESIA
 E  SPECIAL ARTICLE  

Figure 4. Some examples of anatomically malpositioned devices inserted blindly with potentially functional substandard outcomes. ETT indi-
cates endotracheal tube; PVC, polyvinyl chloride; SAD, supraglottic airway device; VLMA, video laryngeal mask airway.

exchange, facilitating spontaneous breathing and The closer the match between the shape of SGD
mechanical ventilation; and (d) protection against air- cuff and pharynx/larynx, the better the seal produced
way trauma with potentially sore throat and cough- by the airway device. When fit is less than optimal,
ing as a consequence. corrective measures need to be taken and a flow chart

Table 1. Grading System Showing Optimally (Grade I), Suboptimally (Grade II), and Unacceptably (Grade III)
Placed SGDs
Devices Anatomically correctly positioned Anatomically poorly positioned
Correctly functioning Ideal perfectly seated device—Grade I Suboptimally positioned SGD—Grade II
• Correct use of size and insertion depth. • Cuff over- or underinflated.
• Epiglottis resting on outside airway device. • Cuff inserted too deep/too superficial.
• Ideally intracuff pressure: 40–60 cm H2O. • Use of an inadequate size.
➔ Producing: ➔ Producing:
   ➢ normal capnogram   ➢ Marginally positioned SGD that needs
   ➢ good air entry and excellent gas exchange adjustments (maneuvers, different size/brand)
   ➢ OPLP >25 cm H2O and Spo2 > 95%   ➢ Airway gas leak; abnormal capnogram; lower
values for OPLP, intracuff pressure, Spo2
Poorly functioning Most common clinical effects of suboptimal placement below Clinically inadequately/unacceptably placed devices—
the cords Grade III
Note: gas leakage and high airway problems which are not ➢E  piglottis downfolding or double-folding leading to
due to misplacement: obstruction.
➢ laryngeal spasm ➢R  etroflexion of tip cuff ➔ prone to gastric inflation
➢ bronchoconstriction and aspiration.
➢ stomach inflation ➢ Cuff jamming between vocal cords.
➢ chest wall rigidity ➔ Producing:
   • severe gas leakage or airway obstruction
   • Inadequate ventilation
   • Very low values of OPLP, cuff pressure and Spo2
➔ Need for immediate corrective actions
Abbreviations: OPLP, oropharyngeal leak pressure; SGD, supraglottic airway device; Spo2, peripheral oxygen saturatiion.

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 Vision-Guided Insertion of Supraglottic Airway Devices or Video Laryngeal Mask Airways
has been developed, describing 3 grades of SGD posi-
tions.30 Corrective maneuvers include: jaw thrust,
chin lift, Magill forceps, a railroading technique over
a gum elastic bougie or Frova/Aintree tube-changer,
adjusting intracuff pressure, size change, insertion
depth change, and use of a different SGD brand or
different insertion technique (eg, videolaryngoscopy-
insertion). Our view is that even if there is no imme-
diate adverse clinical outcome, we should aspire to
optimize positioning of SGDs.
It is already considered unacceptable—in medico-
legal terminology, a breach of duty—to persist with
using an ETT that is malpositioned (eg, questionably
in the trachea, or endobronchial): the recent Project for
Universal Management of Airways (PUMA) guide-
lines have emphasized the importance of ensuring all
positioning criteria are met (especially that of a nor-
mally shaped CO2 waveform with value >1 kPa).32 It
should, therefore, be considered equally unacceptable
to continue anesthesia with an anatomically (as well
as clinically) malpositioned SGD. The fulfillment of
clinical criteria should be documented in the clinical
record after anesthesia induction and SGD placement
(just as we document an ETT has fulfilled signs of tra-
cheal placement); in the future, this should include
the direct visualization of placement, as we subse-
quently discuss.
Good function is not enough; we need cor-
rect anatomical function and optimal seal of the
device. Anesthesiologists should not aim for good
function by chance but based on good anatomical
fit of the device. All anesthesia interventions are
dynamic, and movement or changed characteris-
tics due to surgery may change performance if the
good function is by chance versus through good
anatomical fit.
IS THERE A BEST SGD?
It is pertinent to consider whether certain types of
SGDs are more prone to malposition than others. In
turn, this leads us to a discussion of classification of
SGDs. Categorization attempts for SGDs have pro-
posed various terminologies and classifications, often
based on number of lumina, historical generation of
development, type of sealing mechanism, presence or
absence of a cuff, choice of material, use in unique indi-
cations (eg, LMA®-Gastro™, for gastroscopy, LMA®-
Flexible™ for ENT surgery), or have provided a large
range of brands, sizes, additional features, and modi-
fications. In such schemes, second-generation SGDs,
incorporating both an airway and a gastric tube, are
currently recommended over first-generation venti-
lation-tube-only airway device.33 However, defining
the best SGD is probably an impossible task because
it depends on patient-related factors, the experience of
the operator, the design of the device, the context of its
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use (in/out hospital, during cardiopulmonary resus-
citation, elective/emergency cases) and safety as well
as efficacy, reliability, and cost.18 For example, in low-
income countries, it is arguably the case that cleaning
and reuse advantage of first-generation devices makes
these preferable over second-generation devices.
Therefore, we need to move away from seeking to
define a universal optimum to seeking to insert any
device (of whatever intrinsic characteristics) optimally.
IDEAL POSITION AND OPTIMAL FIT OF SGDs
LEADS TO BETTER FUNCTION
Our central thesis is, therefore, that optimal place-
ment leads to better function, producing 2 adequate
seals, with the gastrointestinal tract (distally with the
esophageal entrance) and with the respiratory tract
(the glottis opening opposing the distal opening of the
airway tube). In some respects, optimal positioning of
a correctly sized SGD depends on anatomical fit of the
device, that is, (a) the distal tip of the cuff rests against
and blocks the upper esophageal sphincter, and allows
an NGT to be inserted into the esophagus via the gas-
tric channel; (b) the distal cuff snugly occupies the
entire hypopharynx; (c) the sides of the cuff face the
pyriform fossae; (d) the epiglottis rests on the outer
side of the cuff and is flattened between the anterior
surface of the proximal cuff and the posterior portion
of the tongue; and (e) the tip of the epiglottis is aligned
with the rim of the proximal cuff, indicating a correct
size is used. However, predicting the optimal size can
be difficult, and is often based on manufacturer’s spec-
ifications (weight and height). In pediatric patients, it
is customary to use dedicated formulas or algorithms
to calculate the ETT size and SGD size. However, a
patient’s anatomy—including an adult patient—does
not always follow ideal textbook measurement and
this underlines the need for direct visual inspection.
NOT ALL PARTS OF DEVICE MANUFACTURING ARE
USEFUL
It is often tempting to assume that, because a device
has taken years to manufacture and overcome hur-
dles in bringing to market, all aspects of the device
have some scientific justification. This may not
always be the case. For example, the aperture bars
on some SGDs have no function; certainly, no pro-
tective role in preventing epiglottis prolapse and
may indeed cause trauma to epiglottis and aryte-
noids.34 They certainly need negotiating with a fiber-
scope so pose an unnecessary barrier in this regard.5
Aperture bars are best avoided.34 Other design fea-
tures of some SGDs, for example, fixation tab, guide
handles, can limit insertion depth by fixation at their
teeth.13 If the stem of the SGD is not long enough
or cannot be inserted deeper into the hypopharynx
because of the presence of a tab obstructed by teeth,
ANESTHESIA & ANALGESIA
 E  SPECIAL ARTICLE  
as malalignment of the proximal rim of the cuff with
the tip of the epiglottis, an epiglottis within the bowl
of the device and ineffective seal with glottis or
esophageal entrance may result.
WHY HAVE THE NEW DIFFICULT AIRWAY
GUIDELINES FROM THE AMERICAN SOCIETY OF
ANESTHESIOLOGY NOT SPECIFIED SECOND-
GENERATION SGDS?
An evidence model is developed and used to guide
the robust literature search for the development
of American Society of Anesthesiologists (ASA)
Practice Guidelines for Management of the Difficult
Airway, providing inclusion and exclusion informa-
tion regarding patients, procedures, practice settings,
providers, clinical interventions, and outcomes.35
Within the text of these Guidelines, literature classifi-
cations are reported for each intervention as follows:
category A level 1, meta-analysis of randomized con-
trolled trials; category A level 2, multiple randomized
controlled trials; and category A level 3, a single ran-
domized controlled trial. Category B level 1, nonran-
domized studies with group comparisons; category
B level 2, nonrandomized studies with associative
findings; category B level 3, nonrandomized studies
with descriptive findings, and category B level 4, case
series or case reports. Statistically significant out-
comes (P < .01) are designated as either beneficial (B)
or harmful (H) to the patient; statistically nonsignifi-
cant findings are designated as equivocal (E). When
available, category A evidence is given precedence
over category B evidence for any particular outcome.
In the development of the 2022 ASA Practice
Guidelines for Management of the Difficult Airway,
first- versus second-generation SGDs were included
in the evidence model for unanticipated/emergency
difficult airways. The literature search revealed insuf-
ficient evidence to evaluate: (1) which type of SGD is
most effective when attempted first after failed intu-
bation, or (2) the most effective order of devices to be
used for attempted intubation or management of an
unanticipated or emergency difficult airway.
To determine whether any of the newer SGDs
offer genuine clinical advantages, properly powered
randomized controlled trials in patients with diffi-
cult airways are needed, both in hospital and in the
prehospital setting. Further study is needed to clas-
sify SGDs according to functionality of the device.
This will help anesthesiologists to make the correct
decision for use of a particular device for a particular
indication because each use demands different per-
formance characteristics.
As with emergency airway access, there are various
SGDs that could be used during difficult airway man-
agement, when indicated, depending on the practitio-
ner’s skill level and the availability of these devices.
Considerations to take into account as to which SGD
February 2024 • Volume 138 • Number 2
Copyright © 2024 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
to use include airway access, duration of surgery,
risk factors for aspiration, practitioner’s experience,
device availability. Second-generation SGDs are likely
to provide better airway protection, and their use is
increasing in clinical practice.
TOWARD VISION-GUIDED INSERTION TECHNIQUE
OF SGDs
Currently, most anesthesiologists will have access
only to videolaryngoscopes (VLS) to facilitate direct-
vision placement of SGDs. The extra instrumentation
of an already crowded oropharynx is a self-evident
constraint. Also, a VLS cannot provide real-time view
of the positioning of the SGD in relation to the vocal
cords. However, VLS does provide some additional
useful information, allowing direct vision placement
of these devices on the basis of the insert-detect-cor-
rect-as-you-go insertion technique, facilitating correct
anatomical and functional optimization.36
Perhaps an advance to VLS is to use a fiberscope to
check the relationship to the vocal cords. This is rou-
tine when the SGD is used as a conduit for tracheal
intubation. In 100 surgical patients, a near-optimal
fiberoptic position of the SGDs (95% of devices cor-
rectly placed anatomically) could be demonstrated,
which contrasts sharply to the 50% to 80% incorrectly
positioned blindly inserted SGDs.36 However, because
the tip of the fiberscope is flexible, and because flex-
ing/extending the tip is necessary to guide the fiber-
scope’s progress, the view of the vocal cords obtained
is often by definition better than the direct juxtaposi-
tion of the airway channel of the SGD to the tracheal
opening: that is, anatomical malposition may still
exist despite a good fiberscopic view of the cords.
A further improvement is of course vision-guided
SGD insertion, where the camera is at the appropriate
tip of the SGD, and this permits, in theory, insertion
under videoscopy of a deflated SGD, pressed against
the hard palate, following the curve of the tongue
and placed between tongue base and hypopharynx,
followed by manipulation of the SGD into the phar-
ynx, such that the SGD tube opening faces the glottic
opening. Under continuous monitoring of the device,
the cuff is inflated using a cuff pressure monitor (ideal
range 40–60 cm H2O) and visual checking whether
the SGD continues to sit correctly after cuff inflation.
Clinical signs should all also be checked and for fur-
ther anatomical confirmation, a fiberoptic scope can
be used.8,37
THIRD-GENERATION VISION-INCORPORATED
VIDEO SGDs
Manufacturers have released 2 early examples of
VLMAs and their physical characteristics and speci-
fications have been described in detail (Figure 3C).8
Both systems use a reusable videoscope, inserted via a
dedicated blind-end channel, terminating in the bowl
www.anesthesia-analgesia.org 345
 Vision-Guided Insertion of Supraglottic Airway Devices or Video Laryngeal Mask Airways
of the SGD, preventing contaminating the videoscope
with bodily fluids. The flexible videoscope allows: (a)
vision of insertion of the SGD in the hypopharynx;
(b) visual check of whether the glottic opening can be
seen; (c) whether the device sits in the midline and is
not rotated in the sagittal plane; and (d) continuous
direct monitoring of the airway if left in place during
the maintenance phase of anesthesia.38 Combining the
second-generation SGD and a videoscope reveals the
advantages of an integrated videoscope into a second-
generation airway device. Both devices are inserted
in one go. The vision-guided technique shows the
first seal (cuff opposing the supraglottic structures),
and prevents the epiglottis downfolding as well as
observing glottis distortion, device rotation, and cuff
misplacement. When using the VLMA as a conduit
for intubation, there is advantage in visualizing the
insertion of the ETT into the trachea and ensuring that
the ETT is advanced to the correct depth, where it is
deployed via the ventilation tube of the SGD. The extra
rim in the bowl of the VLMS device helps to direct the
ETT into the correct orifice—the laryngeal glottic open-
ing. The videoscope is connected directly to a monitor
screen, either using remote access or attached to the
SGD itself. A camera angle adjusting handle (SafeLM)
further helps in navigating the ETT into the correct
position and optimizing the glottic view.
The position of the light source and camera deter-
mines the capability to visualize the whole or part of
the pharynx, glottis, laryngeal view and the device
on the monitor. There is a clear difference in showing
the vocal cords in full when the camera is positioned
either in the midline or on the right or left side. With
the SaCoVLM device (UE Medical), the light source
and camera are positioned on the right side of the
device with the rim on the left side, whereas with the
SafeLM device (Magill Medical Technology), the light
source and camera are positioned on the left side with
the rim on the right side. Classic laryngoscopes and
VLSs usually have the light source on the right side of
the flange of the laryngoscope, as in the camera of a
VLS. This is because most anesthesiologists are right-
handed, and insertion of the airway device is usually
advanced with the right hand.
The presence or absence of a rim in the bowl of the
device affects how the ETT is delivered to the glottic
opening. A 45° rim helps to guide the ETT into position
as the angle at which the ETT passes into the trachea is
almost in-line, that is, in the same plane.8 Without such
a rim, the ETT tends to stick in the mucosal region of
the hypopharynx. The epiglottis is a potential obstacle,
depending on how effectively it is elevated/lifted from
the posterior pharyngeal wall to create an opening for
the airway device to be inserted in the correct place.
With blind SGD insertion, the epiglottis is often down-
folded in the bowl of the airway device. This downfold-
ing of the epiglottis can be partial, resulting in an air
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Copyright © 2024 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
leak, or complete, which may cause total obstruction
of the airway. The latter results in a loss-of-airway and
needs to be corrected immediately. Some users advo-
cate the use of a railroad technique over a gum elastic
bougie or reverse loading of the SGD to avoid epiglottis
downfolding to realize a better position of the SGD.
Video recording and snap shots of still images can
be captured and used for entry into the patient’s health
record, or for teaching and research purposes. The
VLMAs come in 3 sizes for use in adults. Pediatric sizes
of VLMAs are to be expected soon. Table 2 provides a list
of some benefits and advantages of the use of VLMAs.
Anesthesiologists aspiring to improve the quality
of SGD insertion conditions to optimally place SGDs
and to avoid failed or misplaced devices will embrace
these emerging technologies. Early experience with
the VLMAs on patients is promising, although still
not perfect.39–42 Further rigorous testing is needed,
both on manikins and on patients, to demonstrate
that these emerging devices can truly circumvent
unacceptable positioning.
WHAT IS THE FUTURE OF A VISION-GUIDED SGD?
WHAT STILL NEEDS TO BE SOLVED?
The 2 early examples of VLMAs have not solved all
issues. Indeed, they provide a good view of the device
sitting in the hypopharynx and in the sagittal plane
position and have the extra feature of demonstrating
the insertion of the ETT into the trachea under direct
vision. The new VLMAs show the glottis and the
entrance to the trachea. Any fluids (blood, pus, secre-
tions, saliva, frothy sputum [pulmonary edema], aspi-
rate, …) can be clearly seen in real time, in the airway.
Despite all this added information, VLMA still lacks
the view that checks whether the correct SGD size has
been used and does not have a view of the distal cuff
sitting over the entrance of the esophagus.
Improvements in VLMA design are still essential
in our quest for an ideal SGD. We need to see (1) the
SGD sitting in the hypopharynx opposing the glottis
allowing effective gas exchange; (2) the position of
the boundaries, that is, tip of the epiglottis (aligned
with the proximal cuff of the rim of the SGD) dem-
onstrating the use of the correct device and correctly
inflated cuff; (3) the tip of the distal cuff (in entrance
to the esophagus); and (4) have a full view of the
glottis and entrance to the trachea. Additional min-
iaturized cameras and LED lighting can achieve this
easily and are affordable. One lightweight camera-
LED bundles would check the first seal, as if plac-
ing a videoscope through the airway device close
to the airway inlet to evaluate position device and
glottic entrance; a second camera would check the
second seal of the distal gastric drain tube to view
the tip of the distal cuff entry into the esophagus; a
third camera would be placed so as to allow inspec-
tion of the alignment of the proximal cuff with the
ANESTHESIA & ANALGESIA
 E  SPECIAL ARTICLE  

Table 2. Advantages and Benefits of the Use of VLMAs

Benefits and advantages
Technical benefits
Training advantages
Nontechnical/human factors
advantages
Use of digital airway record
(still images or videoclips)
Body posture benefits for
airway managers
Abbreviations: COVID, coronavirus disease; ENT, ear, nose, and throat surgery; SGD, supraglottic airway device; VLMA, video laryngeal mask airways.
• Vision-guided insertion allows visual confirmation of a correctly placed SGD.
• A camera mounted in the bowl of the SGD improves an increased view on the monitor, during the insertion
process and helps to verify its final position whereby the inflated cuff seals off the glottic entrance.
• The force required to insert the SGD is less compared to that required during blind insertion, resulting in less
risk of trauma to soft tissues and laryngeal structures, potentially reducing the incidence of airway bleeding,
damage to the vocal cords and postoperative sore throat.
• Trainers can observe trainees performing SGD insertion on the monitor screen.
• Feedback and guidance can be provided to help the trainee to optimize SGD position.
• Diminished need for the trainer to take over as the trainee will be able to complete the SGD insertion
successfully with trainer guidance in real time.
• Ifvision-guided insertion were to be used for all SGD applications, experience/skills would increase, the
number of malpositioned devices would decrease and patient care would improve.
• The whole team can see the view on the monitor screen, which improves communication and teamwork and
aid in group training.
• Anassistant can support the anesthesiologist in difficult airways and awkward insertion situations. The next
step or plan B can be foreshadowed, and availability of essential equipment can be secured in anticipation
of the request from the anesthesia team.
• Governance and medicolegal advantages will result from vision-guided insertion of SGD into the correct
position.
• Formal training and prolonged trial of VLMAs in the operating complex will lead to changes in perceptions of
departmental consensus with regard to the choice of best new device can be introduced.
• For training purposes: trainees can discuss/review/learn from their own recordings.
• For medicolegal purposes: as a proof of correct positioning of the airway device.
• For use by other specialists, eg, ENT surgeons: diagnosis of additional anatomical/pathological airway
anomalies, vocal cord paralysis, cyst or tumor.
• Correct airway management involves bending or crouching to advice best line of vision of the glottis. VLMA
placement is achieved in the upright position reducing back strain leading to pain, especially in the elderly
anesthesiologist.
• Airway guidelines and recommendations applied during the current COVID-19 pandemic exhort
anesthesiologists to use videolaryngoscopy which can further protect the user from disease exposure.

tip of the epiglottis to verify whether the correct size
SGD has been selected. We either need more cameras
and light sources or more videoscope technology, or
both, in one device. Similar to the cameras and sen-
sors needed to park a car, we need to have a bird’s-
eye view—a panoramic view of the SGD sitting in
the hypopharynx. The panoramic view monitor of
a modern car helps drivers check their vehicle sur-
roundings for hazards and helps them to park cor-
rectly avoiding accidents, even when space is limited
or when there are blind spots by using this park-
ing assist monitoring and surveillance, which uses
4 cameras, mounted on each side of the vehicle to
display a bird’s eye view, projection on to a naviga-
tion screen. A virtual moving see-through view from
the driver’s perspective as through the vehicle were
transparent, allows visibility of a larger and clearer
view and boundary details of the vehicle. It is impor-
tant to have the cameras mounted correctly to maxi-
mize the view and reduce error. More cameras allow
multiple views at the same time. It is even possible
to activate an appropriate camera to show particu-
lar areas of interest and panoramic views of crossing
traffic at junctions and exits, depending on which
direction the vehicle is traveling in. The VLMA view
should be similar to that on a motor car.
Future multicamera technology should be applied to
airway devices, so that correct insertion of the device can
be demonstrated by different cameras angulated in all
directions. Anesthesiologists can then insert the device
into the correct space. Verification of the correct position
of each device placed via the mouth is needed, that is,
SGD, ETT, temperature probe, gastric tube, transesopha-
geal scope, and bronchoscope. Automatic recording adds
further benefits, as it provides proof of where the device
was sitting both at the time of insertion and during the
maintenance phase of anesthesia. These recordings also
prove that the device was positioned correctly and did
not cause the mishap (eg, in case of a respiratory prob-
lem). Miniaturization of cameras, fiberoptics cabling,
high performance LED lighting cameras and Wi-Fi link-
age of device and monitoring should create the basis for
new video laryngeal mask airways (VLMAs).43,44 It is to
be expected that these component parts are ubiquitous,
inexpensive, and readily accessible given the enormous
usage volume which SGDs enjoy.
Training is a vital part of introducing any new air-
way technique. It is clear to understand that vision-
guided insertion of VLMAs is different from blind
insertion of SGDs. Therefore, it is advisable to have
first some formal training, because familiarity with
laryngoscopy or SGD insertion does not equate with
acceptable new skill acquisition of VLMAs. Training is
also vital during a (coronavirus disease 2019 [COVID-
19]) pandemic and other air-borne infectious diseases,
as precise positioning of SGDs would reduce aerosol
generation and risk of infecting anesthesiologists and
other operating room team members.

February 2024 • Volume 138 • Number 2 www.anesthesia-analgesia.org 347

Copyright © 2024 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
 Vision-Guided Insertion of Supraglottic Airway Devices or Video Laryngeal Mask Airways
A separate screen from the VLMA makes it easier
for the trainer to observe actions and to provide guid-
ance/teaching in the operating room. A large screen
is preferred by most anesthesiologists. A screen inte-
grated into the VLMA with the screen attached to the
videoscope is more practical in the prehospital set-
ting, provided the screen allows for clear images vis-
ible in direct sunlight. Airway management outside
the operating complex, using a VLMA, is technically
easier with an integrated VLMA and monitor.
The progression from classic direct laryngoscopy to
videolaryngoscopy and from first- and second-gener-
ation blind inserted SGDs to vision-guided third-gen-
eration SGDs is a bit like the advance from standard
mobile cell phones to smartphones. We believe, simi-
lar to the use of videolaryngoscopy for endotracheal
intubations, which repeatedly have shown to improve
glottic visualization, that VLMAs are first-line options
for airway management with an SGD.
CONCLUSIONS
Although it is too soon to recommend existing VLMAs
as standard, as aspects need to evolve to what might be
considered the ideal, there is enough impetus that the
anesthesia community should embrace and develop
the new technology, with a videoscope embedded
within an SGD. As a first step, we should cease to
accept functionally suboptimally placed SGDs. Practice
changes to promote this include: verbalization to the
team whilst conducting tests of clinical placement cri-
teria (as recommended by PUMA guidance for tracheal
intubation), documentation of fulfillment of these cri-
teria (as we currently do for ETTs), and refusal to take
over patients from colleagues, where the SGD is evi-
dently malpositioned or there is no documentation of
positioning. A second step would be, in our personal
practices, to increase the use of VLS or fiberoptic check-
ing of SGD position to optimize anatomical as well as
functional position. Third, is to use for experience exist-
ing VLMA technology, ideally under the ADEPT and
ADEPT-2 investigative framework, to generate audit
and clinical trial data to inform future developments.
Three-dimensional technology and improved light-
ing in the airway combined with augmented reality,
incorporating videoscopy in airway devices, is prob-
ably the way forward. Multiple cameras will become
increasingly vital in improving airway management.
Ultimately, we should cease using the blind-insertion
technique in favor of a vision-guided insertion tech-
nique of SGDs. E
ACKNOWLEDGMENTS
The authors thank Marie Greco, Graphic Designer and
Medical Illustrator, Clinical Multimedia Unit RBWH, Metro
North Health, Brisbane, QLD, Australia, for her help with
the production of the illustrations.
348   
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Copyright © 2024 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
DISCLOSURES
Name: André A. J. van Zundert, MD, PhD, MSc (Med), FHEA,
FRCA, EDRA, FANZCA.
Contribution: This author helped with the conceptualization
and helped write the article and approved the final version.
Conflicts of Interest: None.
Name: Stephen P. Gatt, MD, MSc, FANZCA, FRCA, FCICM,
FACHSM, AFRACMA.
Contribution: This author helped write the article and
approved the final version.
Conflicts of Interest: None.
Name: Tom C. R. V. van Zundert, MD, PhD, MSc, EDRA, FANZCA.
Contribution: This author helped write the article and
approved the final version.
Conflicts of Interest: None.
Name: Carin A. Hagberg, MD, FASA.
Contribution: This author helped write the article and
approved the final version.
Conflicts of Interest: C. A. Hagberg received funding from
Fisher & Paykel Health Limited, Karl Storz Endoscopy, Lucid
Lane, Teleflex and Vyaire Medical (funded research); Elsevier,
UpToDate (editorial services).
Name: Jaideep J. Pandit, MA, BM, DPHIL, FRCA, DM.
Contribution: This author helped write the article and
approved the final version.
Conflicts of Interest: None.
This manuscript was handled by: Thomas M. Hemmerling,
MSc, MD, DEAA.
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