Do you deflate LMA prior to insertion?

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soorg

soorg

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In training, some attendings would want us to insert deflated, some partially inflated, and a few fully inflated. For the last few years, I've been taking out 2 cc and inserting. I found that inserting the LMA fully deflated causes the tip to fold over sometimes, causing a leak or the need to re-insert. I know the original insertion guide by Archie Brain calls for the LMA to be fully deflated. Just wondering what everyone else does...
 
I dunno. Just a creature of habit. I still slightly deflate my lma when inserting.

Whatever works man.

Some people tape lma and secure it. Some don't.

Some people put lma in 350-400 pounders with reflux for quick cysto or gyn cases as well.
 
Used to always deflate the LMA first (that's what I was taught in residency. A few months ago switched to leaving it the way it comes out of the package with the red tab in place. I've found they seat better on the first try this way and the tip doesn't flip back like it sometimes does with a deflated LMA. Once in place pop off the red tab. 8/10 times I don't find it necessary to add any air to the cuff.
 
I don't care how the LMA is inflated or not inflated. I can put it in in any condition. It's the insertion technique that makes the difference.

But I just grab it, remove the red tab because if left in place it will depress the plunger in the bulb and the LMA will deflate. And I put the LMA in.

But if I can explain my technique here it may help. There was a time that I didn't remove the red tab but I noticed that the LMA when removed was a bit flat or deflated. So since then I now remove the red tab. I insert the LMA midline initially then once the LMA is half way in the mouth I slide it over to the left of the tongue (opposite technique when doing a DL) then advance til past the tongue and more back midline and insert til resistance. I never put my fingers in the mouth but I do grab the forehead and extend the neck some if needed. I usually don't add or subtract any air from the LMA at any time.
 
Just my 2 cents... I do tons of lma as my practice is combo of inpatient and hi volume outpt. surgery.

I don't deflate the LMAs out of packaging. I also use reusable LMAs in one center where the LMAs come back on different states of inflation. once place I inflate as necessary for minimal to no leak. I pull the whole LMA out without deflating always. I also pull LMA out while pt sleeping usually right before they are waking up.

I also do most of shoulders (beach chair and lateral) with an LMA. I also block all my shoulders prior so that helps with the anesthetic. Some surgeons who are usually slower, i will intubate. I also LMA my 350 lb pts unless severe GERD or bad airway with poor access to airway.

I've gotten very comfortable with GA with LMA. So far after 5 years of practice haven't had any issues .

IM not advocating to do any of these things, but Also just don't dismiss it.
 
Igel is a night mare
Did not work the two times I used it
Had to change to regular LMALMA
 
I deflate, I think that when the mouth is small they go in a little easier that way. Don't feel super strong.
 
I insert LMAs with a variety of techniques. I'll deflate it for a small mouth opening or even insert it backwards on occasion. The key is to be atraumatic when inserting an LMA and not rough with a "jamming it in" technique. 99% of the time when you remove an LMA there should NOT be any blood on it. If your LMA has blood on it then keep working on your technique. One last point is that excessive inflation of the LMA is associated with sore throats so add the minimal required amount of air to make a decent seal.

Thee is no one correct way to insert an LMA but there are bad techniques:

1. Excessive force
2. pushing the LMA unnecessarily hard against the posterior pharynx
3. Failing to recognize the LMA isn't seated properly leading to partial obstruction
4. Over inflating the LMA on a routine basis
 
Anyone prefer the Proseal LMA for bigger patients? One of my colleagues does a lot of plastic surgery with Proseal LMAs because the surgeon requests muscle relaxation and he feels more comfortable using the Proseal in those situations...I know most people don't like paralytics and LMAs but plenty of people do fine with this and controlled ventilation.

Also, for those who like pressure control with LMAs (me included), what do you do when the patient starts breath holding from breathing against the positive pressure?
Switching to spontaneous ventilation or pressure support...Propofol bolus...paralytic...jaw thrust...pushing the LMA deeper to get a better seal and applying positive pressure breaths? In what order do you guys prioritize?
 
I slightly deflate the LMA prior to insertion with a tongue blade and then reinflate it just enough to achieve an appropriate seal.
 
You guys should write a book on LMA insertion.
 
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A few other pearls.
Instead of using a tongue blade try using the yankuar without suction on. It has a nice bend in it that allows you to get behind the base of the tongue easily.
Also, if using an LMA in a neonate and you find it won't seat well, try the proseal. It should fit better and if not then pass an OG and follow with the proseal over the OG. Works very well.
 
Noyac said:
Also, if using an LMA in a neonate and you find it won't seat well, try the proseal. It should fit better and if not then pass an OG and follow with the proseal over the OG. Works very well.
Click to expand...

At a talk I attended years ago, this is exactly what Joseph Brimacombe recommended for pro seal insertion.
 
use a manometer to see what inflation pressure you are using. <60cmh2o is recommended by lma but <45cmh2o will reduce sore throats to ~0. If you have never used manometer you will be surprised at what 45cmH2o pressure fells like in a LMA pilot balloon - it will feel like it still needs a bit more. For those who like a little air in the lma before insertion and then add a little more after insertion - your cuff pressures will likely be high.
 
Am a fan of deflating for the small mouthed patients.

Sometimes when it won't insert, I lift the mandible with my thumb at the base of the tongue, which helps with the insertion.

If I have a leak and I'm certain it's inserted correctly, I pack the sides of the oropharynx with 4x4s to occlude any leak. Works like a charm.
 
painstop said:
Anyone prefer the Proseal LMA for bigger patients? One of my colleagues does a lot of plastic surgery with Proseal LMAs because the surgeon requests muscle relaxation and he feels more comfortable using the Proseal in those situations...I know most people don't like paralytics and LMAs but plenty of people do fine with this and controlled ventilation.

Also, for those who like pressure control with LMAs (me included), what do you do when the patient starts breath holding from breathing against the positive pressure?
Switching to spontaneous ventilation or pressure support...Propofol bolus...paralytic...jaw thrust...pushing the LMA deeper to get a better seal and applying positive pressure breaths? In what order do you guys prioritize?
Click to expand...
If it's right after induction: more propofol, reposition/inflate LMA, if still difficult to ventilate sux 20 mg. Usually at this point the problem is solved.

If overbreathing the vent during the surgery: switch to pressure support/SV, fentanyl titrated in 25 mcg boluses, propofol, even sux (20 mg) if needed. The more obese the patient, the faster I jump to sux if I even suspect laryngospasm or I see severely decreasing respiratory volumes.

I give rocuronium only if required by surgery (e.g. abdominoplasty), if SV/PSV interferes with surgery (e.g. hernia repair), or if patient hyperventilating despite everything else being adequate (analgesia, hypnosis, vitals, EtCO2 etc.). I too am a pressure control (vs. pressure support/SV) fan, and have no qualms about relaxing a patient with a good LMA fit (especially if Proseal/Supreme) and good volumes while on PCV. I even blow off the residual gas on PCV at the end of the case, if patient not breathing at about her normal resting EtCO2 and 0.1-0.2 MAC.

On-topic: I deflate LMAs only if appropriate for the patient. If I have a petite, thin lady, I will deflate even the #3 standard LMA enough to be able to pass it easily through her oropharynx. If I have a big obese guy, I don't touch the red tag of the #4/5 Supreme before insertion, but I add extra air after.
 
Last edited by a moderator:
stonemd said:
use a manometer to see what inflation pressure you are using. <60cmh2o is recommended by lma but <45cmh2o will reduce sore throats to ~0. If you have never used manometer you will be surprised at what 45cmH2o pressure fells like in a LMA pilot balloon - it will feel like it still needs a bit more. For those who like a little air in the lma before insertion and then add a little more after insertion - your cuff pressures will likely be high.
Click to expand...
+1. I use a manometer for all LMAs and cuffed ETTs. I also recheck pressures later in the case since I use N20
 
nimbus said:
I induce and insert LMAs in the prone position in selected patients with their head turned to the side. When doing this, I noticed that all the LMAs slide in very easily. So now when I encounter resistance in supine patients, I turn their head to the side and they slip right in.
Click to expand...
Gonna try this. Thanks for the tip
 
soorg said:
In training, some attendings would want us to insert deflated, some partially inflated, and a few fully inflated. For the last few years, I've been taking out 2 cc and inserting. I found that inserting the LMA fully deflated causes the tip to fold over sometimes, causing a leak or the need to re-insert. I know the original insertion guide by Archie Brain calls for the LMA to be fully deflated. Just wondering what everyone else does...
Click to expand...
Sometimes depends on the airway but usually fully inflated and a weekend's worth of surgilube
 
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