LMA: inflated vs deflated insertion?

[zyovka]

Just finished my Peds rotation where LMAs were heavily utilized. Our institution ran out of reliably working some "whatever brand" "pinkish" classic LMAs and whatever left (some blue colored) seem sort of more rigid and hard to put in. We tried to adjust and it appears like deflated insertion worked better. I googled and opinions differ. Initially LMAs were created to be inserted with the cuff deflated, but some research states that insertion of inflated LMA facilitates less airway injury and improves success of insertion. Any opinion from experienced ppl here? Thanks

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[FiO2@21]

We have off-brand green LMA Uniques, for what it’s worth as a CA-2 I keep them inflated. Lube generously, pressing hard against the palate when inserting.

My problem with deflating is that they ended up crumpled up half the time.

 

[abolt18]

Just finished my Peds rotation where LMAs were heavily utilized. Our institution ran out of reliably working some "whatever brand" "pinkish" classic LMAs and whatever left (some blue colored) seem sort of more rigid and hard to put in. We tried to adjust and it appears like deflated insertion worked better. I googled and opinions differ. Initially LMAs were created to be inserted with the cuff deflated, but some research states that insertion of inflated LMA facilitates less airway injury and improves success of insertion. Any opinion from experienced ppl here? Thanks

We primarily have the Uniques. The instructions for use (IFU) specifically state that you should deflate it for insertion then inflate it prior to attaching it to your circuit so it can inflate into place without other things influencing its seating in the oropharynx. Then hook it up and tape if you desire.

We have an attending who is obsessed with reading the IFU on every single piece of equipment in the OR that you use and he'll make you read it before you use that equipment. (Once made me Google then read the IFU prior to inserting the LMA while he masked the patient) It hurts the soul sometimes, but I'll admit I have learned some good nuggets from doing it.

 

[coffeebythelake]

At my institution we use LMA unique with integrated cuff pressure indicator (exactly as pictured).
Usually just lube it up with no changes made to prior to insertion.
Then make adjustments after placement to ensure cuff pressure is appropriate.
Haven't had any issues placing them with this technique, 1st attempt success nearly 100%

I don't know if there was a significant redesign of these LMAs from the original, but I think they work great. Very easy to place, seals well, almost never does the tip curl around with placement.

In the past when we used AmbuAuras we deflated the cuff before insertion. They were more difficult to use, sometimes bloodied the airway, and tip curl was a recurring problem.

 

[dannyboy1]

LMA’s are imperfect. Sometimes they just don’t sit well no matter what you do. I’ve tried every variation (inflated, deflated, curved design, put it in backwards and turn it around) in some patients they just don’t sit well...

 

[anbuitachi]

LMA’s are imperfect. Sometimes they just don’t sit well no matter what you do. I’ve tried every variation (inflated, deflated, curved design, put it in backwards and turn it around) in some patients they just don’t sit well...

im impressed you shoved it in there and then turned it around
A+ for effort

 

[coffeebythelake]

LMA’s are imperfect. Sometimes they just don’t sit well no matter what you do. I’ve tried every variation (inflated, deflated, curved design, put it in backwards and turn it around) in some patients they just don’t sit well...

If you had enough room to put it in backwards and turn it around, maybe you should have chosen a larger size LMA??

 

[zyovka]

At my institution we use LMA unique with integrated cuff pressure indicator (exactly as pictured).
Usually just lube it up with no changes made to prior to insertion.
Then make adjustments after placement to ensure cuff pressure is appropriate.
Haven't had any issues placing them with this technique, 1st attempt success nearly 100%

I don't know if there was a significant redesign of these LMAs from the original, but I think they work great. Very easy to place, seals well, almost never does the tip curl around with placement.

In the past when we used AmbuAuras we deflated the cuff before insertion. They were more difficult to use, sometimes bloodied the airway, and tip curl was a recurring problem.

View attachment 311576

Yup, yup. We used to have these and they were perfect. Never failed. Now we have a different one and it is a pain to make them sit well

 

[Lashler9054]

use the i-gel. You’ll never look back

 

[linkin06]

I don't deflate it completely, but I test it by inflating a little and deflate back to original stock size (slight inflation). If it sits well like that, i'll just add minimal air.

 

[2Fast2Des]

In residency we had Igel, they were great, but now in PP have the inflatable. I have tried the inflated method but I've had more difficulty, and more success deflating slightly and reinflate as needed to get the pressure in the green zone on the indicator. Ymmv

 

[nimbus]

I don't deflate it completely, but I test it by inflating a little and deflate back to original stock size (slight inflation). If it sits well like that, i'll just add minimal air.

What are you testing for? Have you ever had one fail a test?

 

[coffeebythelake]

What are you testing for? Have you ever had one fail a test?

do you check your ETT cuffs? probably the same idea

 

[nimbus]

do you check your ETT cuffs? probably the same idea

No. Also never had one fail.

 

[deleted697127]

We have off-brand green LMA Uniques, for what it’s worth as a CA-2 I keep them inflated. Lube generously, pressing hard against the palate when inserting.

My problem with deflating is that they ended up crumpled up half the time.

In my opinion, more force is rarely the answer in anesthesia.

Positioning helps, ideally sniffing with the jaw open. If the patients head is propped up too much on pillows the angle isn’t as forgiving. I have the patient tilt their chin up towards me right as they are drifting off. If you anticipate difficulty, have a second set of hands open up the jaw for you. The goal is atraumatic. Don’t worry about being needy if you have an assistant help hold the jaw. If you do have trouble with an LMA, take note of your positioning and see if there is anything you could have done differently in the future.

IGels are nice but I would highly recommend messing around with every type of LMA you can get your hands on during residency. I would bet most independently owned surgery centers are going with whatever the cheapest option they can find is.

 

[Southpaw]

Air in/out is pseudoscience to me. I put the lma in as it comes after lubing it up a good bit. I give it less than 1 minute to get a good seal and I make sure the patient is either nice and deep when I place it OR still spont vent when I place and once it in they keep ridin on w Sevo on board. Occasionally I’ll add some air, 10cc or less, but no more.

if in that minute or so I can’t get a good seal I move on and intubate, unless it’s going to be a super short case and I’m good enough. I don’t worry about it or think much about it any longer either. Some people you just can’t get a good seal in.

 

[anbuitachi]

No. Also never had one fail.

i test all the cuffs when i set up for ET. ive had 1 that was clearly not holding air

 

[Orin]

We have an attending who is obsessed with reading the IFU on every single piece of equipment in the OR that you use and he'll make you read it before you use that equipment. (Once made me Google then read the IFU prior to inserting the LMA while he masked the patient) It hurts the soul sometimes, but I'll admit I have learned some good nuggets from doing it.

The product inserts on drugs and instructions for use are probably the least appreciated thing in the OR setting, next to the anesthesiologist of course.

The key point for LMAs is that different manufacturer's and versions have different best practices. You're all bright people, but I assume the manufacturers have some rationale for things until proven otherwise. We can argue about how to tape a tube all we want, but LMA placement at least we should start the discussion from the IFU/manual/etc method first, which varies a lot both on insertion and removal.

 

[anbuitachi]

The product inserts on drugs and instructions for use are probably the least appreciated thing in the OR setting, next to the anesthesiologist of course.

The key point for LMAs is that different manufacturer's and versions have different best practices. You're all bright people, but I assume the manufacturers have some rationale for things until proven otherwise. We can argue about how to tape a tube all we want, but LMA placement at least we should start the discussion from the IFU/manual/etc method first, which varies a lot both on insertion and removal.

i wonder how they tested. did they test on real people? manniquins?

 

[DrOwnage]

I insert with it right out of the packaging, no need to deflate. Lube well. The main barrier to placing one well is the rigid triangle where the cuff extends from. I scissor open the mouth like I do when I DL, Put the LMA with my non-dominant hand so that the rigid triangle portion is at about the soft palate. Then take the hand I used to scissor the mouth open and slide it behind the LMA, guiding the rigid portion past the soft palate and basically shooting it down the oropharynx. This ensures that there is no trauma from the rigid portion, and the tip of the LMA never curls and you don't get a weird leak where you have to pull up and down to make it seat better. This has been key, always works.

 

[norski]

I insert inflated with generous lube nearly every time, find that the semi hard cup of the unique is less likely to scratch up any soft tissue. If any resistance is met, I wiggle the lma about 90 degrees before advancing. Usually pretty smooth way to do it, especially in spont vent anesthetics. If leakage occurs after manipulating the head and neck, I try the iGel, and if I'm still getting issues, I intubate.

The times I insert deflated would be where the patient has a small mouth opening and I need room to maneuver. If issues with leakage going that route, McGrath with mac blade is brought out.

 

[urge]

im impressed you shoved it in there and then turned it around
A+ for effort

Used to be a taught technique by some attendings in the good old days when LMAs were novel.

Felt unnecessary, and borderline dangerous, to me.

 

[urge]

I deflate my self. Seems logical to me.

I let my trainees place it inflated if that’s what they are used to.

 

[Lidolover]

Inflated, sufficient gel not only on the dorsal surface but also on the trunk of the LMA and pt’s lip, tongue depressor to hold tongue from getting into your way... and boom, effortlessly and with finesse

 

[norski]

Inflated, sufficient gel not only on the dorsal surface but also on the trunk of the LMA and pt’s lip, tongue depressor to hold tongue from getting into your way... and boom, effortlessly and with finesse

I like the tongue depressor idea. A laryngoscope also works really well.

 

[Lidolover]

I like the tongue depressor idea. A laryngoscope also works really well.

was this a joke? Because for me joke is seeing ppl struggling with your fingers in pt’s mouth to reposition the LMA or to bring the tongue out of the way.
The tongue depressor holds just the tip of the tongue; u don’t insert it down to the palate.

ps: finesse is a privilege of few ...

 

[J Peterman]

Unique: Remove from packaging (including plastic). Place LMA on hard surface with tip towards me and convexity of tubing facing up. With fingers in a V and LMA tip in the crotch of the V, press down and deflate LMA. About 15cc for a 3, 20cc for a 4, 30cc for a 5. It will be perfectly flattened with no “creases” and a slight convexity to help match the curvature of the hypopharynx. Lube both sides. Tilt patient’s head back (to open mouth), insert tongue depressor, goal is not to place any part of my hand in their mouth if possible. I usually slide the LMA in at 90 degrees down the R gutter (along the tongue) and then do a 90 degree scoop to slide it into position. This technique works well for me at least.

 

[deleted697127]

was this a joke? Because for me joke is seeing ppl struggling with your fingers in pt’s mouth to reposition the LMA or to bring the tongue out of the way.
The tongue depressor holds just the tip of the tongue; u don’t insert it down to the palate.

ps: finesse is a privilege of few ...

I’ve never used a laryngoscope for LMAs but i dont see what’s wrong with the idea if someone wants to try it to make a placement less traumatic. I wouldn’t recommend it on every patient but this is a thread asking for tips and different techniques. I am 100000% on board with sharing and trying different techniques that work for other people in an effort to get better as long as i don’t see them as being dangerous. Doing the same thing every time won’t make you better. (Not convinced im going to start using a laryngoscope for LMAs but i get the thought process.)

What’s the counter argument for not using a laryngoscope other than that it’s not typical? Eye roll if the argument is stimulation and you probably didn’t push narcotic. Cause yea you weigh pros and cons of all decisions.

Place more LMAs is the obvious answer for improving technique.

 

[coffeebythelake]

I’ve never used a laryngoscope for LMAs but i dont see what’s wrong with the idea if someone wants to try it to make a placement less traumatic. I wouldn’t recommend it on every patient but this is a thread asking for tips and different techniques. I am 100000% on board with sharing and trying different techniques that work for other people in an effort to get better as long as i don’t see them as being dangerous. Doing the same thing every time won’t make you better. (Not convinced im going to start using a laryngoscope for LMAs but i get the thought process.)

What’s the counter argument for not using a laryngoscope other than that it’s not typical? Eye roll if the argument is stimulation and you probably didn’t push narcotic. Cause yea you weigh pros and cons of all decisions.

Place more LMAs is the obvious answer for improving technique.

Do u give muscle relaxation before u DL for LMA placement?

 

[norski]

I’ve never used a laryngoscope for LMAs but i dont see what’s wrong with the idea if someone wants to try it to make a placement less traumatic. I wouldn’t recommend it on every patient but this is a thread asking for tips and different techniques. I am 100000% on board with sharing and trying different techniques that work for other people in an effort to get better as long as i don’t see them as being dangerous. Doing the same thing every time won’t make you better. (Not convinced im going to start using a laryngoscope for LMAs but i get the thought process.)

What’s the counter argument for not using a laryngoscope other than that it’s not typical? Eye roll if the argument is stimulation and you probably didn’t push narcotic. Cause yea you weigh pros and cons of all decisions.

Place more LMAs is the obvious answer for improving technique.

Lidolover: the laryngoscope was not meant as a joke, actually something I've done from time to time (not by any stretch of the imagination on a regular basis) . No need to push the blade deep into the vallecula, but if there's trouble with placement, it allows me to at least guide the LMA tip gently in place, or just ask my colleague to give me a tube instead. Mostly remi or fent and prop, sometimes ketofol inductions.

I don't have tongue depressors available, but mac blades are plentiful.

 

[norski]

Do u give muscle relaxation before u DL for LMA placement?

Probably not directed at me, but no relaxation for DL-LMA on my end. Remi is a hell of a drug. Most of my intubations even, sans RSIs, are done with only prop and remi/fent.

 

[deleted697127]

Do u give muscle relaxation before u DL for LMA placement?

Misread that. I don’t think anyone was ever suggesting DLing and looking at the cords

 

[Arch Guillotti]

Probably not directed at me, but no relaxation for DL-LMA on my end. Remi is a hell of a drug. Most of my intubations even, sans RSIs, are done with only prop and remi/fent.

Really? I like this induction but the old and frail don’t always tolerate it great.

 

[coffeebythelake]

Probably not directed at me, but no relaxation for DL-LMA on my end. Remi is a hell of a drug. Most of my intubations even, sans RSIs, are done with only prop and remi/fent.

u use remi for your regular intubations? u must rack up a hell of a bill.

 

[norski]

u use remi for your regular intubations? u must rack up a hell of a bill.

Only where I plan to use remi TCI for the rest of the anesthetic. 2mg vial mixed with 40ml NaCl,split into two syringes (often two patients). Otherwise fent (frail, elderly, kids) or alfentanil. Cheap enough.

Really? I like this induction but the old and frail don’t always tolerate it great.

Bradycardia can be an issue, so depending on baseline, some glyco or atropine is preferred up front. Any real reduction in EF, I go prop/fent/roc.

 

[Velefunt]

• mostly deflated

 

[deleted162650]

Well I’m glad we’re all in agreement and got this straightened out.

 

[deleted697127]

Not pushing opiate helps too. Want to get them just barely apneic for a few seconds.

 

[deleted875186]

I’ll second the no opioids for LMA insertion, they aren’t needed, plus the patient is breathing spontaneously faster.

That being said, the opioid on induction for intubation can usually be cut out as well.

 

[secretasianman]

I keep it simple and dry dog it. No lube. Straight out of package. Head tilt. 45-90deg wiggle and it slips in easy. Feels good.

 

[deleted162650]

I keep it simple and dry dog it. No lube. Straight out of package. Head tilt. 45-90deg wiggle and it slips in easy. Feels good.

Strong contender for best double entendre of 2020.

 

[secretasianman]

If it doesn’t feel good you’re doing it wrong.