Role of laryngeal mask airway in emergency department and pre-hospital environment

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1 Hong Kong Journal of Emergency Medicine Role of laryngeal mask airway in emergency department and pre-hospital environment FKC Chu LMA and Intubating LMA (LMA-Fastrach) have been widely used by anesthesiologists in operation theaters and have achieved great success. Its use in the emergency department and pre-hospital setting by EMS has recently been proven to be very successful. It is also a very useful tool in providing a quick airway in case of failed intubation and failed ventilation situations. In this article, some of its use in emergency departments and pre-hospital setting are discussed. (Hong Kong j.emerg.med. 2003;10:57-62) Keywords: Emergency department, laryngeal mask airway Introduction The Laryngeal Mask Airway (LMA) was introduced by a British anesthesiologist Archie Brain in the 1980s. 1 However it has only been used in Emergency Medicine and pre-hospital setting recently. It was initially designed to bridge the gap between facemask and endotracheal tube. It provides a better airway than the facemask with less dead space. On the other hand, it does not require neuromuscular blockade or laryngoscopy for placement. It is also better tolerated than intubation. Thus, it has gained widespread popularity and is being extensively used in patients undergoing general anesthesia. More recently, it has become a tool for difficult or failed intubations in the ASA (American Society of Anesthesiologists) Difficult Airway Management Algorithm. 2 With the modification of the usual Laryngeal Mask Airway, a new prototype of LMA-Intubating LMA (ILMA or LMA-Fastrach) was developed. It offers broader applications in the emergency department and Correspondence to: Chu Kin Chiu, Francis, MBBS(HK), MRCP(UK) Queen Elizabeth Hospital, Accident and Emergency Department, 30 Gascoigne Road, Kowloon, Hong Kong chu00338@i-cable.com pre-hospital setting. 3 It is designed to provide a quick airway and to assist intubation. This article reviews the development, advantages and disadvantages of Laryngeal Mask Airway (LMA) and Intubating LMA and particularly its role in the emergency department and pre-hospital environment. History The LMA was invented by a British anesthesiologist Dr. A.I.J. Brain in London in By examining postmortem specimens of the larynx, Brain noted that an airtight seal could be achieved around the laryngeal inlet by an inflated cuff in the hypopharynx. Prototype LMA was developed from molds made from Plaster of Paris of cadaveric pharynx and the Goldman dental mask. After years of developments, the first LMA was commercially available in Britain in 1988 and was approved by the FDA in US by Nowadays, commercially available LMA is manufactured from medical-grade silicon and consists of an obliquely cut tube mounted into the concave central part of an oval mask. (Figure 1) Also, different sizes and types of LMA, including the Classic and the intubating LMA (Fastrach, as shown in Figure 2) are available.

2 58 Hong Kong j. emerg. med. Vol. 10(1) Jan 2003 Figure 1. Laryngeal mask airway. Figure 2. Intubating laryngeal mask airway. Insertion of LMA Preparation Before every use, the LMA should be checked for cracks and whether it has been sterilized as LMA is a reusable device. The cuff should be deflated so that the tip forms a flat leading edge. Then the convex surface, but not the concave side of the LMA should be lubricated. Lubricating the concave side may lead to aspiration of lubricant, resulting in coughing and laryngospasm. Although the LMA can be inserted under topical anesthesia, it is normally inserted under general anesthesia. Correct insertion requires an adequate level of anesthesia to obtund pharyngeal reflexes. In contrast to endotracheal intubation, muscle relaxants are unnecessary. Intravenous induction agents, together with opioids (such as fentanyl or alfentanyl) are adequate for insertion in most circumstances. Among all the available induction agents, Propofol in the dose of mg/kg seems to be the best for insertion of LMA. Techniques of insertion Unlike intubation, insertion of LMA can be achieved in a high proportion of patients with little practice. Therefore LMA can be used widely in emergency and pre-hospital setting. In one study, 4 comparing success and time to airway management by paramedics and respiratory therapists in anesthetized and paralysed patients, insertion of an LMA required a mean of 39s with a mean of 1 attempt/patient success as compared with 206s for an ETT with 2.2 attempts/patient success. No one failed to insert an LMA but 10 out of 19 could not intubate. Proper insertion technique is necessary for optimal placement and poor technique may lead to the loss of airway. Standard insertion technique is described in the LMA instruction manual and is summarized below. Following adequate amount of induction agent and narcotics until jaw relaxation is achieved, place the patient in the "sniffing the morning air position" with neck flexed and head extended if cervical spine immobilisation is not required. Place the lubricated LMA into the mouth, press it back against the hard-palate with the index finger to flatten the LMA. Now, it is important to check that the rim of the LMA does not fold back on itself at this stage. Then slide the LMA behind the tongue and into the pharynx until a definite resistance is felt to indicate that it has reached its final location. The cuff should then be inflated. During inflation, the LMA should be free to move and it will invariably centre itself over the laryngeal opening. Confirmation of proper position can be achieved by end-tidal CO 2 detection, or by observing movement of reservoir bag. A black line printed along the posterior surface of the LMA tube gives a visual confirmation of the correct position.

3 Chu/Role of laryngeal mask airway 59 Clinical use of LMA (1) LMA as an airway for operation: It is primarily designed as an alternative to simple facemask for protected and assisted ventilation in certain surgical procedures in which endotracheal intubation is not required. A further advantage is that the anesthesiologist can free his hand for other task, such as drug administration. (2) LMA as an emergency airway: Recently, in algorithms published by both the American Society of Anesthesiologists and the European Resuscitation Council, the LMA is considered a primary option for the management of difficult airway and failed airway patients. 2 (Figure 3) Although endotracheal intubation is the most secure way to control and maintain the airway, it can sometimes be very difficult, even in experienced hands. Maintaining ventilation with bag-valve mask can also become difficult especially in edentulous or bearded patients. Moreover, maintaining ventilation using bagvalve mask often requires two hands to make a tight seal and LMA, in this circumstance, can free the resuscitator for injection or chest compression. Literature review showed only one reported case of failure to ventilate in a patient with LMA. 5 Some studies have shown that LMA has been used successfully by physicians, nurses and paramedics, regardless of patient's position. The LMA can also be placed in patients with fixed neck deformity and limited mouth opening as a result of facial burn. 6 (3) To facilitate intubation through LMA: A 6-mm internal diameter endotracheal tube (ETT) can be passed through the tube of size 3 and 4 LMA. If the LMA is well lubricated and correctly positioned, the ETT can be inserted blindly through the aperture into the larynx. Successful intubation rate can be up to 90%. However, after introduction of the special Intubating LMA, blind intubation through LMA becomes less common. A size 6 ETT may be too small for an adult male, the insertion of a larger ETT can be facilitated by using the gum-elastic bougie. A gum-elastic bougie is inserted through the LMA and act as a guide-wire. 7 With the removal of the LMA, larger size ETT can be inserted into the larynx through the bougie. In order to improve accuracy, the ETT can be mounted onto the fiberoptic brochoscope which is then passed through the LMA. 8 This technique allows the vocal cord to be visualized. It avoids blind intubation, and increases the success rate. It is useful in paediatric patients since ILMA is not available in paediatric patients. Figure 3. An algorithm showing the use of LMA in difficult and failed airway management. (4) Resuscitation: Besides acting as an immediate airway, LMA can also be used as a conduit for administration of

4 60 Hong Kong j. emerg. med. Vol. 10(1) Jan 2003 medications during resuscitation. In one study, considerable amount of adrenaline was found in pulmonary tree after it is injected down a seated LMA in cadaver. 9 However, similar results are not demonstrated in other studies. 10 Thus, it is suggested that during resuscitation, in those patients who have no airway nor venous access, injection of medication down the LMA may be worth the attempt, but the outcome is not as reliable as via the ETT. Advantages of using LMA in ED The LMA can be easily placed and provides a quick and adequate airway with relatively few complications. It is easy to learn. Thus it can be used by physicians, nurses, and paramedics to provide quick airway during resuscitation, especially for those who are inexperienced in intubation or in cases of failed intubation. In a study concerning pre-hospital airway management by ambulance officers in Australia, the overall success rate of LMA insertion was 80%. 11 It is better than bag-valve mask since one can free his hand for other resuscitation process and it is more secure than the bag-valve mask. In an unanticipated difficult intubation, LMA can provide a temporary airway to prevent desaturation, while one can buy time to call for assistance, perform surgical airway or re-intubate through the LMA with or without gum-elastic bougie or fiberoptic bronchoscope. LMA can be placed even if the patient has fixed neck deformity, or needs cervical spine immobilisation, or is in a prone or lateral position. In trauma victims who are trapped, and those who need to secure the airway quickly, LMA can provide a better airway than facial mask, and under this unfavourable occasion, it is rather difficult for paramedics or even emergency physicians to intubate the victims. Complications of LMA Complications are rare with its use in the operation room. Unlike the ETT, it does not protect from aspiration of gastric content and other secretion. Laryngospasm occurs when the patient is not deepened enough during insertion. These are not actually significant in patients undergoing elective surgery since most of them have been fasted for an adequate period before operation. Brimacombe conducted a metaanalysis of the published literature in 1995 and found that the incidence of aspiration was only 2/10000 with LMA 12 which was similar to that recorded during general endotracheal anaesthesia. However, it is a major problem in our patients in Emergency Department. Most of them have not been fasted, thus regurgitation and aspiration can be a serious problem. Like the rapid sequence induction, cricoid pressure should be exerted and maintained continuously after placement to reduce regurgitation and aspiration of gastric contents in patients who are at high risk of aspiration like (1) those after prolonged bagging, (2) pregnancy, (3) morbid obesity, and (4) those with upper gastrointestinal bleeding. Positive pressure ventilation, although possible in LMA if the pressure does not exceed 20 cm H 2 O, 13 is relatively contraindicated. It leads to air leak and promotes gastric distention and aspiration. Therefore, it may not be suitable in situations of severe asthma or acute pulmonary oedema. Misplacement of LMA will lead to obstruction. Improper insertion of LMA may fold the epiglottis and thus obstruct the airway. Over inflation of the LMA cuff may impose pressure on the hypopharynx and could cause pressure necrosis. Compression on nerve can result in dysarthria, which is usually transient. Tongue cyanosis has been reported due to occlusion of the lingual artery by LMA. 14

5 Chu/Role of laryngeal mask airway 61 The Intubating Laryngeal Mask Airway (ILMA) Laryngeal Mask Airway has provided a quick airway for patients with difficult intubation with great success. However, for patients seen in emergency department (ED) and Emergency Medical Services (EMS), a definite airway is usually preferred. By modification of the LMA, a new prototype has now been developed the Intubating LMA (ILMA). ILMA consists of a short, anatomically curved, rigid, stainless steel shaft that follows the oral, pharyngeal, and laryngeal axes of the airway, allowing facile alignment of the mask with the glottis. It has a metal handle that aids in insertion and manipulation of the device. There is a V- shaped ramp that guides the ETT through the mask aperture directly and a moveable but rigid epiglottis elevating bar that lifts the epiglottis out of the way of the advancing ETT. It is particularly useful in the ED and EMS setting when compared to the standard LMA as it can assist intubation, minimise head and neck movement, and therefore particularly useful in patients with cervical spine injury. Insertion technique The insertion of ILMA is different from that of the usual LMA in several ways. 15 The technique involve the following steps: 1. Keep the patient's head in neutral position, rather than in slightly extension. 2. Hold the intubating LMA by its handle and position the mask tip flat against the hard palate just inside the mouth and immediately posterior to the upper central incisors. Then slide the mask tip slightly back and forth to coat the hard palate with lubricant. 3. Slide the mask backwards, following the curve of the tube with fingers of the other hand to open the mouth slightly. 4. Swing the entire device downward into place, then inflate and secure. Indications that the ILMA is correctly positioned include (i) the ability to generate an airway pressure of 20 cm H 2 O, and (ii) the ability to ventilate manually. 5. Pass the appropriate-sized wire-reinforced tube through the ILMA with lubricants. 6. If resistance is encountered, it is most likely due to the downfolding of the epiglottis or lodging of the tube against the vestibular wall. Rotating the ETT bevel may solve the problem. 7. If difficulty is encountered, it is possible to try smaller sized ETT or to guide the ETT with the help of a fiber-optic bronchoscope. 8. Finally, the ILMA can be removed or can be left behind after the ETT is inserted. A number of studies have shown that ILMA has a high success rate but the learning curve is somewhat steeper than the usual LMA. 16 Case reports have also demonstrated the successful use of ILMA in patients with cervical spine injury undergoing rapid sequence induction. 17 Thus, for emergency department staff and emergency medical service providers, Intubating LMA offers an attractive option for emergency airway management in the "cannot intubate and cannot ventilate scenario". It can provide an emergency airway even though intubation may not be achieved. The ILMA should not be used for a prolonged period once a definite airway is achieved since it may result in pressure necrosis of the pharyngeal mucosa. Conclusion The American Society of Anesthesiology has introduced the use of LMA and the ILMA as a tool for emergency airway management in situations when one "cannot intubate or cannot ventilate".

6 62 Hong Kong j. emerg. med. Vol. 10(1) Jan 2003 Both the LMA and the newer ILMA are easy to use and require only little training to master the technique. They are very suitable for use in emergency department and by pre-hospital medical service providers for patients with difficult airway. References 1. Brain AI. The laryngeal mask: a new concept in airway management, Br J Anaesth 1983;55(8): Practice guidelines for management of the difficult airway. A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 1993;78: Rosenblatt WH, Murphy M. The intubating laryngeal mask: use of a new ventilating-intubating device in the emergency department. Ann Emerg Med 1999;33(2): Reinhart DJ, Simmons G. Comparision of placement of the laryngeal mask airway with endotracheal tube by paramedics and respiratory therapists. Ann Emerg Med 1994;24(2): Patel SK, Whitten CW, Ivy R 3rd, Macaluso A, Pennant J. Failure of the laryngeal mask airway: an undiagnosed laryngeal carcinoma. Anesth Analg 1998;86(2): Thomson KD, Ordman AJ, Parkhouse N, Morgan BD. Use of the Brain laryngeal mask airway in anticipation of difficult tracheal intubation. Br J Plast Surg 1989; 42(4): Chadd GD, Ackers JW, Bailey PM. Difficult intubation aided by the laryngeal mask airway. Anaesthesia 1989; 44(12): Silk JM, Hill HM, Calder I. Difficult intubation and the laryngeal mask. Eur J Anaesthesiol 1991;Suppl 4: Challiner A, Rochester S, Mason C, Anderson H, Walmsley A. Spread of intrapulmonary adrenaline administered via the laryngeal mask. Resuscitation 1997;34: Alexander R, Swales H, Pickford A, Smith GB. The laryngeal mask airway and the tracheal route for drug administration. Br J Anaesth 1997;78(2): Grantham H, Phillips G, Gilligan JE. The laryngeal mask in pre-hospital emergency care. Emerg Med 1994; 6: Brimacombe JR, Berry A. The incidence of aspiration associated with the laryngeal mask airway: a metaanalysis of published literature. J Clin Anesth 1995;7 (4): Asai T, Morris S. The laryngeal mask airway: its features, effects and role. Can J Anaesth 1993;40(10): Wynn JM, Jones KL. Tongue cyanosis after laryngeal mask airway insertion. Anesthesiology 1994;80(6): Brain AIJ, Verghese C. LMA-Fastrach instruction manual. San Diego, CA: Laryngeal Mask Co., Ltd.; Baskett PJ, Parr MJ, Nolan JP. The intubating laryngeal mask. Results of a multicentre trial with experience of 500 cases. Anaesthesia 1998;53(12): Schuschnig C, Waltl B, Erlacher W, Reddy B, Stoik W, Kapral S. Intubating laryngeal mask and rapid sequence induction in patients with cervical spine injury. Anaesthesia 1999;54(8):793-7.

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