Selected topics: critical care
The laryngeal mask airway: A comprehensive review for the Emergency Physician1

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Abstract

The Laryngeal Mask Airway (LMATM) was developed in the 1980s, but has only recently begun to be used in Emergency Medicine. The LMA affords effective assisted ventilation without requiring endotracheal intubation or visualization of the glottis. In doing so, it is more efficacious than a bag-valve-mask apparatus, although the risk of aspiration of gastric contents persists, particularly if the device is not properly placed. The LMA also has significant potential utility in management of the difficult airway. Most reported clinical experience with the LMA has come from the operating room. This article provides an overview of the extensive potential utility of the LMA in the Emergency Department and prehospital settings as well as a comprehensive review of the pertinent advantages, disadvantages, and complications associated with its use.

Introduction

The Laryngeal Mask Airway (LMATM) was developed by the British anesthesiologist Archie Brain in the 1980s. It was originally designed to permit ventilation and maintain a patent airway that was intermediate in intensity and invasiveness between the facemask and the endotracheal tube (ETT). Brain envisioned the LMA as a physical junction between the artificial and the anatomic airways, allowing some maintenance of protective reflexes and less dead space ventilation (and greater reliability) than with a facemask, but without assumption of complete control of the patient’s airway by the operator (1).

In the current decade, Brain’s invention has enjoyed widespread popularity in the operating room (OR). The LMA allows either spontaneous or positive-pressure ventilation, with or without administration of anesthetic gases. More recently, it has received additional attention as a tool for the management of the difficult airway (2). In this latter role, it has entered the armamentarium of the Emergency Physician (EP). In the Emergency Department (ED), the LMA can be used as a rescue ventilation device that provides a temporizing airway in the patient or as a conduit to intubation after failure by more routine approaches. The recent development of the intubating LMA (LMA-FastrachTM) by Brain offers even broader applications in the ED and the prehospital [emergency medical service (EMS)] environment.

To date, more than 1,500 articles have been published on the LMA, but few of these view the device and its use from the unique perspective of the EP. It is the goal of this review to present the LMA in the context of Emergency Medicine practice.

Section snippets

The device

The LMA was designed after the careful study of plaster casts of cadaver airways. Brain found that by inflating an elliptical cuff in the hypopharynx, an airtight seal could be achieved around the larynx posteriorly. This approach required reliable avoidance of downfolding of the epiglottis and of obstructive folding of the epiglottis within the mask orifice during insertion (1). Brain adapted a Goldman dental mask with 10 mm tubing and first used a prototype device on a patient in 1981 1, 3.

Summary: The LMA and intubating LMA for ED and EMS use in the future

The LMA has earned a secure role in the OR for routine surgical use and in the management of difficult intubations and frank airway emergencies. Because of its clear utility in this regard, there is no sound argument to be made for limiting its use to these settings. The inclusion of the LMA in advanced airway management algorithms for other specialties mandates the education of ED and EMS providers in this technique. That it affords ventilation even in the absence of intubation, that the

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    Selected Topics: Critical Care Medicine is coordinated by Joseph Varon, MD, of Baylor College of Medicine, Houston, Texas

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