Don’t Underrepresent the Risks Associated with the Use of a Laryngeal Mask Airway



Don’t Underrepresent the Risks Associated with the Use of a Laryngeal Mask Airway


Surjya Sen MD



A 57-year-old, otherwise healthy professional concert singer presents for an elective outpatient prostate biopsy for suspected adenocarcinoma. He has a healthy body mass index (BMI), and physical exam indicates that he would be a grade 1 intubation. He reports that 10 years ago he experienced hoarseness and prolonged throat and mouth pain after intubation for an emergency appendectomy. He concludes this bit of history by volunteering, “I almost sued the guy that jammed that tube down my throat; I couldn’t do my concert dates for two months.” He had surgery for a meningomyocele as an infant (wouldn’t you just know), so a spinal is out. He inquires whether there are any other options. When you suggest a laryngeal mask airway, he replies, “Well, that sounds great, Doc, but are there any drawbacks to having anesthesia with this ‘ellemae’ thing?”

In 1983, Dr. Archie Brain introduced the laryngeal mask airway (LMA) as a device to secure the airway without the use of direct laryngoscopy. By 1988 the LMA became commercially available worldwide, and by 1991 the U.S. Food and Drug Administration had approved its use in the United States. Soon thereafter, the device gained rapid popularity because of its advantages over other options for airway control—namely, direct laryngoscopy with endotracheal intubation or bag-mask ventilation (Table 15.1). These days, the LMA is an essential piece of equipment on every emergency airway cart and has become nearly ubiquitous in outpatient anesthesia. Despite its many advantages, however, the use of an LMA does carry a small but significant set of risks. Every anesthesia provider should be familiar with these risks—not only to recognize potential complications if they occur, but also to counsel patients properly when requesting informed consent.


DISADVANTAGES AND COMPLICATIONS


LMA Misplacement.

The first requirement to placing an LMA successfully is proper positioning. Problems such as a folded tip, supraglottal placement, and an improper seal over the upper esophagus can usually all be resolved with repositioning. Just as with endotracheal intubation, verification of proper LMA placement immediately after insertion is imperative.
End-tidal capnography, bilateral breath sounds, and auscultating over the laryngopharynx for evidence of leaks should be essential parts of a preliminary check after initial positioning. The placement should be periodically verified throughout the case and after any repositioning of the patient.








TABLE 15.1 SOME ADVANTAGES OF THE LMA

































▪

Use in an ACLS algorithm for difficult airway.


▪

Use in the absence of trained personnel to perform tracheal intubation or surgical airway.


▪

Use when direct laryngoscopy equipment malfunctions.


▪

Use in reactive airway disease when endotracheal intubation may be overstimulating.


▪

Less intraocular pressure increases when compared to endotracheal intubation.


▪

Less local trauma and better hemodynamic stability during insertion than with direct laryngoscopy and endotracheal intubation.


▪

Less incidence of “sore throat” and “hoarse voice” when compared to endotracheal intubation.


▪

Less gastric insufflation when compared to face-mask ventilation.


▪

Better air-tight seal, less hand fatigue, and more stability than a face mask.


▪

Less manipulation of the patient’s head, neck, and jaw.

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Jul 1, 2016 | Posted by in ANESTHESIA | Comments Off on Don’t Underrepresent the Risks Associated with the Use of a Laryngeal Mask Airway

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