LMA

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Slide 1: 

LARYNGEAL MASK AIRWAY meena

INTRODUCTION : 

INTRODUCTION An ingenious supraglottic device designed to provide and maintain seal around the laryngeal inlet for spontaneous as well as controlled ventilation. Invented in 1983 by Dr. Archie Brain as a modification of the Goldman Dental Mask Commercially available in UK in 1988 FDA approved in May 1991

Introduction continued : 

Introduction continued The LMA design: Based on anatomic and physiologic studies of human pharynx Provides an “oval seal around the laryngeal inlet” once the LMA is inserted and the cuff inflated. Once inserted, it lies at the crossroads of the digestive and respiratory tracts.

Slide 4: 

LMA-Flexible™ LMA-Classic™ LMA-Unique™ LMA-Fastrach™ LMA Cuff Deflator 1988-2000 T Y P E S

The Intubating LMA-Fastrach™ : 

The Intubating LMA-Fastrach™

The LMA ‘Proseal’– a Laryngeal Mask With an Oesophageal Vent : 

The LMA ‘Proseal’– a Laryngeal Mask With an Oesophageal Vent

LMA-CTrach™ : 

LMA-CTrach™

Slide 8: 

LMA Supreme

LMA Classic / Unique : 

LMA Classic / Unique LMA Classic- reusable / LMA Unique disposable Silicone , no latex / PVC It has three parts 1. air way tube 2. inflatable mask 3. inflation system

Slide 10: 

Airway tube – Slightly curved, semi rigid, semi transparent Apertures - two a) proximal aperture fused with silicone connector b) distal aperture opens in to inflatable mask, crossed by two aperture bars Attached to the back of the mask at an angle 30˚. A black line runs along the posterior curvature of the tube.

Slide 11: 

Inflatable mask– Inflatable mask is oval shaped. Proximal end- broad and round Distal end- narrow and pointed. Mask has two parts a) inflatable cuff and b) concave back plate. Cuff is attached to the outer rim of back plate.

Slide 12: 

Inflation system - Attached to proximal portion of the cuff in mid line and has four component - 1. long narrow inflation tube 2. pilot balloon 3. a spring loaded valve 4. a syringe port.

Preparation of theLMA for Insertion : 

Preparation of theLMA for Insertion Step 1: Size selection Step 2: Examination of the LMA Step 3: Check deflation and inflation of the cuff Step 4: Lubrication of the LMA Step 5: Position the Airway

LMA Classic : 

LMA Classic

Step 2: Examinationof the LMA : 

Step 2: Examinationof the LMA Visually inspect the LMA cuff for tears or other abnormalities Inspect the tube for any discoloration or debris Flex the tube to 180 degrees check for any kinks

Aperture bars & connections are intact

Step 3: Deflation and Inflation of the LMA : 

Step 3: Deflation and Inflation of the LMA Slowly deflate the cuff to form a smooth flat wedge shape to ensure that it will maintain a vacuum Inflate the cuff completely to ensure that it does not leak

Step 4: Lubricationof the LMA : 

Step 4: Lubricationof the LMA Use a water soluble lubricant to lubricate the LMA Only lubricate the LMA just prior to insertion Lubricate the back of the mask thoroughly Important Notice: Avoid excessive amounts of lubricant on the anterior surface of the cuff or in the bowl of the mask. Inhalation of the lubricant following placement may result in coughing or obstruction.

Step 5: Positioningof the Airway : 

Step 5: Positioningof the Airway Extend the head and flex the neck Avoid LMA fold over: Assistant pulls the lower jaw downwards. Visualize the posterior oral airway. Ensure that the LMA is not folding over in the oral cavity as it is inserted.

INDUCTION : 

INDUCTION Insertion requires obtundation of airway reflexes by general or topical anaesthetics or muscle relaxation to prevennt any adverse response. Topical anaesthetics Inhalational agents IV anaesthetic agents+/- opoids Muscle relaxants Adequacy of anaesthesia? AWAKE PLACEMENT

LMAInsertionTechnique : 

LMAInsertionTechnique

LMA Insertion Step 1 : 

LMA Insertion Step 1 Grasp the LMA by the tube, holding it like a pen as near as possible to the mask end. Place the tip of the LMA against the inner surface of the patient’s upper teeth

LMA Insertion Step 2 : 

LMA Insertion Step 2 Under direct vision: Press the mask tip upwards against the hard palate to flatten it out. Using the index finger, keep pressing upwards as you advance the mask into the pharynx to ensure the tip remains flattened and avoids the tongue.

LMA Insertion Step 3 : 

LMA Insertion Step 3 Keep the neck flexed and head extended: Press the mask into the posterior pharyngeal wall using the index finger.

LMA Insertion Step 4 : 

LMA Insertion Step 4 Continue pushing with your index finger. Guide the mask downward into position.

LMA Insertion Step 5 : 

LMA Insertion Step 5 Grasp the tube firmly with the other hand then withdraw your index finger from the pharynx. Press gently downward with your other hand to ensure the mask is fully inserted.

LMA Insertion Step 6 : 

LMA Insertion Step 6 Inflate the mask with the recommended volume of air. Do not over-inflate the LMA. Do not touch the LMA tube while it is being inflated unless the position is obviously unstable. Normally the mask should be allowed to rise up slightly out of the hypopharynx as it is inflated to find its correct position. The black line on the tube should face the upper lip in midline.

The mask has to enter the circular path as shown here, all the time being pressed into the curve of the palate : 

The mask has to enter the circular path as shown here, all the time being pressed into the curve of the palate zz

Slide 29: 

UES patent (cuff deflated) UES ‘blocked’ (cuff inflated) Potential for ‘spillage’ No potential for spillage

Verify Placement of the LMA : 

Verify Placement of the LMA Connect the LMA to a Bag-Valve Mask device or low pressure ventilator Ventilate the patient while confirming equal breath sounds over both lungs in all fields and the absence of ventilatory sounds over the epigastrium Rising of cricoid and thyroid cartilage Lifting of the barrel out of the mouth by upto 1 cm Bag movement capanography

Slide 31: 

Method for Verification of Correct Positioning of LMAs except Proseal

Few Other Techniques : 

Few Other Techniques Thumb insertion technique 180 degree tilt Lateral tilt Introducer Technique Jaw Thrust Laryngoscope Partial cuff inflation

LMA -- Thumb Insertion Technique : 

LMA -- Thumb Insertion Technique

Problems withLMA Insertion : 

Problems withLMA Insertion Failure to press the deflated mask up against the hard palate or inadequate lubrication or deflation can cause the mask tip to fold back on itself.

Problems withLMA Insertion : 

Problems withLMA Insertion Once the mask tip has started to fold over, this may progress, pushing the epiglottis into its down-folded position causing mechanical obstruction

Problems withLMA Insertion : 

Problems withLMA Insertion If the mask tip is deflated forward it can push down the epiglottis causing obstruction If the mask is inadequately deflated it may either push down the epiglottis penetrate the glottis.

Slide 37: 

Maintenance of Anesthesia Removal of the LMA Cleaning, Sterilization and Re-use

Determining Life Span of LMA : 

Determining Life Span of LMA intended for 40-50 uses, but highly over-manufactured tube remains translucent aperture bars remain intact cuff deflates correctly no valve leakage cuff remains symmetric pilot balloon retains shape connector remains tight/ not broken

Complications Arising from Use of the LMA : 

Complications Arising from Use of the LMA Aspiration of gastric contents Gastric distention Foreign body aspiration Airway obstruction Trauma to epiglottis post. Pharyngeal wall uvula, soft palate, tongue, tonsils Dislodgement Damage to LMA Nerve injury- hypoglossal/recurrent laryngeal/lingual bronchospasm Coughing Sore Throat

USES OF LMA : 

USES OF LMA LMA and the Difficult Airway Difficult MASK Airway Blind Intubation Failed Intubation Fiberoptic Bronchoscopy and the LMA Emergent Intubation by an Unskilled Provider

LMA and Difficult Airways : 

LMA and Difficult Airways

LMA and Difficult Airways : 

LMA and Difficult Airways

LMA and Difficult Airways : 

LMA and Difficult Airways

LMA-Classic™ and Fastrach™ in Trauma (Dr A. Mason) : 

LMA-Classic™ and Fastrach™ in Trauma (Dr A. Mason)

Slide 45: 

LMA and Pediatric Anesthesia - subglottic stenosis -difficult airway- Ophthalmic surgery Thyroid surgery Professional singers Supplementation of regional blocks Resuscitation Out of hospital use Laser surgery Neurosurgery

Contraindications to Using the LMA : 

Contraindications to Using the LMA Full Stomach Non-fasted 34+ week pregnant trauma acute abdomen thoracic injury opiate premedication autonomic neuropathy patient unable to follow instructions any condition known to delay gastric emptying

Contraindications to Using the LMA : 

Contraindications to Using the LMA Full Stomach Patients with a history of GE reflux Patients with low pulmonary compliance needing positive pressure ventilation Glottic or subglottic airway obstruction Mouth opening <1.5 cm

Advantages of LMA over ETT : 

Advantages of LMA over ETT increased speed and ease of placement by inexperienced personnel increased speed of placement by anesthetists improved hemodynamic stability at induction and during emergence minimal increase in intraocular pressure following insertion

Advantages of LMA over ETT : 

Advantages of LMA over ETT reduced anesthetic requirements for airway tolerance lower frequency of coughing during emergence improved oxygen saturation during emergence lower incidence of sore throats in adults

Advantages of LMA over Face Mask : 

Advantages of LMA over Face Mask easier placement by inexperienced personnel. improved oxygen saturation. less hand fatigue. improved operating conditions during minor pediatric otological surgery.

Additional Advantages of Using the LMA : 

Additional Advantages of Using the LMA leaves provider’s hands free patient can produce effective cough allows spontaneous ventilation even malpositioned can adequately ventilate

Disadvantages of LMA over the ETT : 

Disadvantages of LMA over the ETT lower seal pressure higher frequency of gastric insufflation Disadvantages of LMA over the FM esophageal reflux more likely

Flexible LMA : 

Flexible LMA Silicone / reusable Airway tube - long, small diameter, flexible, nonkinkable, wire reinforced. Used for head and neck surgery Sizes (6) 2, 2.5, 3, 4, 5, 6

I – LMA / LMA Fastrach : 

I – LMA / LMA Fastrach Used for tracheal intubation. It has anatomically curved, short, wide tube of s/s covered with silicone, attached to mask and guiding handle. At distal aperture – a single epiglottis elevator bar and V shaped guiding ramp. Inflation system is same as in classic LMA

I – LMA / LMA Fastrach : 

I – LMA / LMA Fastrach Sizes available (3) 3 4 5 ETT size 7 7.5 8 Supplied with stabilizing rod and ETT - cuffed, silicone, armoured tube especially designed for ILMA. Used with pt. in neutral position

LMA Proseal : 

LMA Proseal Silicone/ reusable Double tubes 1. Airway tube - wire reinforced, flexible 2. Drain tube - passes through the ventral aspect of the mask, opens at the tip of the cuff. Additional cuff on the back of mask – better seal. Bite block No aperture bar. Placed with a metallic introducer.

LMA-ProSeal™ -- The Concept : 

LMA-ProSeal™ -- The Concept Drainage tube Airway tube

LMA Proseal : 

LMA Proseal Advantages - Gastric tube insertion - Diversion of regurgitated fluid - Prevents gastric insufflations Used for IPPV and spontaneous ventilation Available sizes – (6) X, 1.5, 2, 2.5, 3, 4, 5, X

LMA C Trach : 

LMA C Trach Device is VVI - ventilation, visualization and intubation. ILMA with integrated fibreoptic technology. Screen at the proximal end of LMA CT. Direct vision of larynx and intubation.

Slide 61: 

LMA Supreme

Design : 

Contour of Airway Tube to Backplate optimized for easy insertion Design

Design : 

Patented ‘’Fins’ maintain airway even with large epiglottis Tab for securing device after insertion Design

Take Home Message : 

Take Home Message routinely test the cuff before use avoid lubricating the anterior surface of the mask only insert the LMA when an adequate depth of anesthesia has been obtained maintain an adequate anesthetic depth throughout surgery avoid disturbing the patient during emergence keep the cuff inflated until the patient is awake

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