Selected topics: critical careThe laryngeal mask airway: A comprehensive review for the Emergency Physician1
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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Cited by (51)
Comparison of laryngeal mask airway vs tracheal intubation: a systematic review on airway complications
2017, Journal of Clinical AnesthesiaCitation Excerpt :However, for surgical procedures requiring muscle relaxation, mechanical positive-pressure ventilation is required to secure airway ventilation. To achieve PPV with an LMA, a higher cuff pressure can be used but this does not provide an airtight seal and creates a risk of regurgitation and pulmonary aspiration [5,6]. Obesity, laparoscopic surgery, and gastroesophageal reflux may be relative contraindication for the use of LMA.
Dysphagia, hoarseness, and globus in a postoperative patient
2015, American Journal of Otolaryngology - Head and Neck Medicine and SurgeryCitation Excerpt :A larger LMA was also associated with a higher incidence of sore throat at 24 hours. Inappropriate size, cuff overinflation, aspiration of gastric contents, local irrigation, direct trauma, improper placement, positive pressure, and bronchoconstriction have all been postulated as causes of postoperative complications [5]. When symptoms persist or worsen after 24 hours, additional diagnoses like arytenoid dislocation, vocal fold immobility, and airway foreign bodies should be considered.
Endotracheal Tube and Respiratory Care
2013, Handbook of Polymer Applications in Medicine and Medical DevicesAirway management and acute airway obstruction
2013, Oh's Intensive Care Manual, Seventh EditionEndotracheal Tube and Respiratory Care
2013, Benumof and Hagberg's Airway ManagementEndotracheal Tube and Respiratory Care
2012, Benumof and Hagberg's Airway Management: Third Edition
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Selected Topics: Critical Care Medicine is coordinated by Joseph Varon, MD, of Baylor College of Medicine, Houston, Texas