When to pull out the LMA?

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Colba55o

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What is the current opinion on when the appropriate time is to pull out an LMA during a typical say..uro case in an ASA II patient?
I'm currently a CA1; I used to wait until the patient opened eyes, followed commands and practically took it out themselves before pulling it. Realizing that was overkill, I've been doing what a CA3 taught me: wait until the moment they first start to move and then quickly pull it. Patients have been tolerating this pretty smoothly.
I have one attending, however who wants me to pull it deep...as in he wants me to deepen the patient to 1.2-1.3 mac and then pull it, even if its a patient whos been doing well running at 0.8 mac through the case. He told me to then pop in an oral airway and then mask them😕
This seems to be a more laborious way of doing things. I understand the indications for extubating deep (avoiding bucking, theoretical reduced risk of laryngospasm and post op sore throat etc) but do these same justifications apply for pulling an LMA deep?
Running them at 100% high flow FIO2 gives me valuable minutes to tend to other things while I wait for the surgeons and nurses to finish applyiing dressings, putting in foley catheters etc. Doesn't pulling the LMA deep force you to tie yourself to the head of the bed, making sure they are not obstructing?
Ultimately the core question I have is, is it riskier to pull an LMA out when a patient is light than deep?
Thx in advance!
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Colba55o said:
What is the current opinion on when the appropriate time is to pull out an LMA during a typical say..uro case in an ASA II patient?
I'm currently a CA1; I used to wait until the patient opened eyes, followed commands and practically took it out themselves before pulling it. Realizing that was overkill, I've been doing what a CA3 taught me: wait until the moment they first start to move and then quickly pull it. Patients have been tolerating this pretty smoothly.
I have one attending, however who wants me to pull it deep...as in he wants me to deepen the patient to 1.2-1.3 mac and then pull it, even if its a patient whos been doing well running at 0.8 mac through the case. He told me to then pop in an oral airway and then mask them😕
This seems to be a more laborious way of doing things. I understand the indications for extubating deep (avoiding bucking, theoretical reduced risk of laryngospasm and post op sore throat etc) but do these same justifications apply for pulling an LMA deep?
Running them at 100% high flow FIO2 gives me valuable minutes to tend to other things while I wait for the surgeons and nurses to finish applyiing dressings, putting in foley catheters etc. Doesn't pulling the LMA deep force you to tie yourself to the head of the bed, making sure they are not obstructing?
Ultimately the core question I have is, is it riskier to pull an LMA out when a patient is light than deep?
Thx in advance!
Click to expand...

You'll get used to time management aspects with practice. Induction and emergence are the most critical times in my view. So yes, you should be glued to the patient. Take care of other things earlier or later.

During my peds rotation there was one attending who loved to pull LMAs deep and he got me very comfortable with it. What I was always taught is that whether it is an LMA or an ETT, the same rule applies: When you pull it, they are either awake or they are deep. Never pull it in between for risk of triggering laryngospasm.
 
In general, with an LMA, I pull it deep on about 1 MAC of Sevo in 100% O2. Prior to that I've gotten them spontaneously breathing with support. A minute or so before pulling, I place the machine on manual, removing the support. They usually slowly start breathing again, with larger volumes over a minute or 2. Than I pull it and place an OPA. Done. Rarely do I have to support them with PPV from a mapleson. I pull the LMA immediately prior to moving them to the transport gurney and going to the PACU. If they had problems in stage 2, I would likely already be in the PACU, and not the hall with no help and limited meds/equipment. There may be cases where it is better to pull the LMA awake, but I probably would choose a tube for those patients. I don't think I would pull the LMA when they were in stage 2, as you mentioned above (your 3rd year's "tip"). That's asking for trouble. They are either deep or awake, not light and in the "danger zone".
YMMV.

Colba55o said:
What is the current opinion on when the appropriate time is to pull out an LMA during a typical say..uro case in an ASA II patient?
I'm currently a CA1; I used to wait until the patient opened eyes, followed commands and practically took it out themselves before pulling it. Realizing that was overkill, I've been doing what a CA3 taught me: wait until the moment they first start to move and then quickly pull it. Patients have been tolerating this pretty smoothly.
I have one attending, however who wants me to pull it deep...as in he wants me to deepen the patient to 1.2-1.3 mac and then pull it, even if its a patient whos been doing well running at 0.8 mac through the case. He told me to then pop in an oral airway and then mask them😕
This seems to be a more laborious way of doing things. I understand the indications for extubating deep (avoiding bucking, theoretical reduced risk of laryngospasm and post op sore throat etc) but do these same justifications apply for pulling an LMA deep?
Running them at 100% high flow FIO2 gives me valuable minutes to tend to other things while I wait for the surgeons and nurses to finish applyiing dressings, putting in foley catheters etc. Doesn't pulling the LMA deep force you to tie yourself to the head of the bed, making sure they are not obstructing?
Ultimately the core question I have is, is it riskier to pull an LMA out when a patient is light than deep?
Thx in advance!
Click to expand...
 
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Colba55o said:
What is the current opinion on when the appropriate time is to pull out an LMA during a typical say..uro case in an ASA II patient?
Click to expand...

My general approach is similar to yours.

If I'm going to wait for them to be awake, or the timing works out that way, I treat it like an oral airway - they'll take it out when they're ready.

If deep, 100% O2, a MAC or more, pull it, oral airway in, strap the mask to the face, and periodically chin lift if they're obstructing. Usually you can finagle a good position with towels or whatever and that'll free up your hands.

I guess the bottom line is, I treat it like an oral airway in either case.
 
Why bother removing the ultimate oral airway. They never cough or gag on it when waking up, they just wince a little and pull it out. My patients remove it and hand it to me either immediately before or just after moving from the OR table to the gurney for transport.

Once in a long while a surgeon will surprise me with an "I'm done", and then I take them to PACU with the LMA in and they usually pull it out as I am giving report.

Less stimulating and more effective than a Geudel type oral airway, and I don't know anyone who is bothered by having those in while the patient is half awake in PACU or in transport there.

- pod
 
periopdoc said:
Why bother removing the ultimate oral airway. They never cough or gag on it when waking up, they just wince a little and pull it out. My patients remove it and hand it to me either immediately before or just after moving from the OR table to the gurney for transport.

Once in a long while a surgeon will surprise me with an "I'm done", and then I take them to PACU with the LMA in and they usually pull it out as I am giving report.

Less stimulating and more effective than a Geudel type oral airway, and I don't know anyone who is bothered by having those in while the patient is half awake in PACU or in transport there.

- pod
Click to expand...

Never had someone cough or gag on an LMA? Hmmmm. I usually take mine out deep so it's not a problem, and when I take them out awake, MOST of the time they don't really cough much - but they can and do cough and gag on them, and I've seen two bitten in half.

You're lucky you can take yours to PACU with an LMA in. Our nurses would have a friggin cow.
 
I pull it when I'm ready. Turn the agent off once the stimulation is predictably over in a few min. Turn the flows up a couple min before I pull. I generally leave it in as long as the pt is tolerating. If the ET% is approaching .3%, I'll pull it. If they look like they're starting to swallow, I'll pull it. Otherwise, I just pull it before we move to the stretcher.

Can't say I know which stage they are in, aside from my own prediction based on ET%. I used to wait until the last possible second, challneging myself to remove it after they atrted swallowing but before they bit the thing. I'm much more cavalier now.

I'm more catious in kids, though, who are at higher risk of spasm.

I generally don't like pulling them deep, as that almost invariably leads to soft tissue obstruction, which means my hands are tied up with a chin lift. Plus they're less responsive in PACU. If I think they'll obstruct, I'd rather leave the LMA in until they're lighter. I personally don't undertsand the point of removing one supraglottic device for another, certainly not as a pre-meditated plan.
 
I view it as a more convenient way to do a mask case, so I usually take it out deep. When the surgeons start closing the skin I convert to a regular mask case. The LMA lets me have my hands free for charting (or reading or whatever) during the case. Otherwise I didn't need it in the first place so taking it out deep anywhere along the way is probably ok. It's just most convenient for me to take it out toward the end, but before gagging some awake kid with it. As a resident I was usually told not to take it out until the patient was awake. I still leave it in if I think masking will be difficult, but I typically take it out deep now and haven't had any issues.
 
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GypsySongman said:
I view it as a more convenient way to do a mask case, so I usually take it out deep. When the surgeons start closing the skin I convert to a regular mask case. The LMA lets me have my hands free for charting (or reading or whatever) during the case. Otherwise I didn't need it in the first place so taking it out deep anywhere along the way is probably ok. It's just most convenient for me to take it out toward the end, but before gagging some awake kid with it. As a resident I was usually told not to take it out until the patient was awake. I still leave it in if I think masking will be difficult, but I typically take it out deep now and haven't had any issues.
Click to expand...

Masking someone for an anesthetic is almost a lost art. I was already in anesthesia for 15 years before LMA's came along, so it was either mask or tube. It was not uncommon in anesthesia school to do a 3hr mask case. You'd be surprised at the tricks and gimmicks used to maintain a mask airway on a long case. However, in private practice, the unwritten #1 reason to place an ETT was convenience of the anesthetist so that you had your hands free to do something else. The LMA has eliminated a lot of intubations, but us old farts took a LONG time to make the change, and I still do cases with a mask on occasion.
 
There's not too much I would mask anymore. We had LMAs in training, but I did a few 60-90 min long masks, for educational purposes of course.😉
If it's booked for more than 5 minutes, the LMA's going in. I use them in MRI and GI all the time. If you're obstructing much after induction, you get an LMA. Sometimes I place one after the EGD in a spont vent pt for upper and lower scopes.
 
Idiopathic said:
i dont preach very often but this is something that I say at least three times a week to various students
Click to expand...

rsgillmd said:
You'll get used to time management aspects with practice. Induction and emergence are the most critical times in my view. So yes, you should be glued to the patient. Take care of other things earlier or later.

During my peds rotation there was one attending who loved to pull LMAs deep and he got me very comfortable with it. What I was always taught is that whether it is an LMA or an ETT, the same rule applies: When you pull it, they are either awake or they are deep. Never pull it in between for risk of triggering laryngospasm.
Click to expand...


This is what I was taught as well, but I no longer buy it. The risk of laryngospasm is slightly higher than pulling an OA, but not much. I don't pull 'em deep because I'm too lazy to mask, and quite often you have to place an OA to mask anyway (why pull out the LMA OA?). I don't pull em awake because I hate it when they bite em. I had a teenager get negative pressure pulmonary edema after biting a particularly well seated LMA on emergence once. Classic -sats in the 80's, pink frothy sputum - CPAP in the PACU for 6hrs prior to discharge.

I pull it at 0.3-0.4 MAC while spont ventilating. Sometimes the patient opens their eyes as I pull it. My n is still relatively low finishing residency, but haven't had a single laryngospasm yet.
 
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Why are people masking patients after they pull out the LMA? One of the points of an LMA is to keep patients spontaneously ventilating. If they obstruct after you pull it, then place an oral airway and give them a jaw thrust.
 
IlDestriero said:
In general, with an LMA, I pull it deep on about 1 MAC of Sevo in 100% O2. Prior to that I've gotten them spontaneously breathing with support. A minute or so before pulling, I place the machine on manual, removing the support. They usually slowly start breathing again, with larger volumes over a minute or 2. Than I pull it and place an OPA. Done. Rarely do I have to support them with PPV from a mapleson. I pull the LMA immediately prior to moving them to the transport gurney and going to the PACU. If they had problems in stage 2, I would likely already be in the PACU, and not the hall with no help and limited meds/equipment. There may be cases where it is better to pull the LMA awake, but I probably would choose a tube for those patients. I don't think I would pull the LMA when they were in stage 2, as you mentioned above (your 3rd year's "tip"). That's asking for trouble. They are either deep or awake, not light and in the "danger zone".
YMMV.
Click to expand...

You are talking about kids ( I assume) and he is talking about adults.
One of our attendings used to pull the LMA deep ( kids) and when they were breathing spontaneously, even giving 10-15 mg of propofol before puling --> oral airway --> on a side --> kids sleeping peacefully in PACU. I loved the technique. However, I am not doing kids anymore....
 
Arch Guillotti said:
Why are people masking patients after they pull out the LMA? One of the points of an LMA is to keep patients spontaneously ventilating. If they obstruct after you pull it, then place an oral airway and give them a jaw thrust.
Click to expand...

When I talked about masking after lma, I wasn't talking about positive pressure ventilation. I'm using the mask to deliver gas/O2 to the patient and return exhaled gas to scavenging, but spontaneous ventilation continues.

Not sure about everyone else.
 
GypsySongman said:
When I talked about masking after lma, I wasn't talking about positive pressure ventilation. I'm using the mask to deliver gas/O2 to the patient and return exhaled gas to scavenging, but spontaneous ventilation continues.

Not sure about everyone else.
Click to expand...

got it👍
 
jwk said:
Never had someone cough or gag on an LMA? Hmmmm. I usually take mine out deep so it's not a problem, and when I take them out awake, MOST of the time they don't really cough much - but they can and do cough and gag on them, and I've seen two bitten in half.
Click to expand...

Not since 2nd year of residency. If they are biting/ coughing/ gagging they probably need a touch more fentanyl.

I had an attending in residency who was a true master of the art of the LMA. He would have the patient move to the gurney by himself, then have them pull out their own LMA. I am not that good although I did finally get a patient to calmly remove their own ETT on command at the end of a case the other day.

I used the proseal with the built in bite block to practice. Now, I just use whatever LMA is available.

jwk said:
You're lucky you can take yours to PACU with an LMA in. Our nurses would have a friggin cow.
Click to expand...

I have only taken two patients to PACU in the last 6 months with an LMA in. I removed the LMA myself. I am not sure what the nurses would say if I started doing it routinely, but I doubt they would like it.

At one of my hospitals in residency we would occasionally let the PACU nurses pull them when the patient was ready. They were all cross trained for the ICU, and our PACU frequently served as ICU overflow, and so we didn't feel that it was significantly different than the ETT extubations they did all the time. If we had a lower extremity nerve block to do, we would leave the LMA/ ETT in, take the patient to PACU on a propofol drip, do the block, then let the nurses wake them up and extubate. I wouldn't do that in my current institution since we aren't staffed for it, but I don't have a philosophical problem with it.

As with everything, patient selection is key... you simply do not leave your 98-year-old pulmonary cripple or 9-month-old kid with recent URI in the hands of someone who can't intervene to rescue the airway if needed, but in the average patient...

- pod
 
Great info. I was wondering as well, how many of you guys deflate the lma before putting it in? Is that standard practice (I do and have noticed a better fit with but got a questionable look from attending last week doing it)
Cheers
 
nycitygas said:
Great info. I was wondering as well, how many of you guys deflate the lma before putting it in? Is that standard practice (I do and have noticed a better fit with but got a questionable look from attending last week doing it)
Cheers
Click to expand...

I equilibrate it with ambient pressure. Usually that means I'm inserting air. I get a better seal that way, but I'm not sure there's a right answer.

Like choosing the right DL blade, or a hundred other decisions we make daily, you do what works best for you.
 
I don't deflate it before placement nor do i before removing it.
BTW 1 mac of volatile to pull an LMA in adults is way too much.
 
nycitygas said:
Great info. I was wondering as well, how many of you guys deflate the lma before putting it in? Is that standard practice (I do and have noticed a better fit with but got a questionable look from attending last week doing it)
Cheers
Click to expand...

i put it in straight out of the package, and i think there are better published success rates with inflated vs. fully deflated. some people have told me they think it is less likely to fold over on itself with all the air out, but I dont have much of a frame of reference for that
 
slavin said:
This is what I was taught as well, but I no longer buy it. The risk of laryngospasm is slightly higher than pulling an OA, but not much. I don't pull 'em deep because I'm too lazy to mask, and quite often you have to place an OA to mask anyway (why pull out the LMA OA?). I don't pull em awake because I hate it when they bite em. I had a teenager get negative pressure pulmonary edema after biting a particularly well seated LMA on emergence once. Classic -sats in the 80's, pink frothy sputum - CPAP in the PACU for 6hrs prior to discharge.

I pull it at 0.3-0.4 MAC while spont ventilating. Sometimes the patient opens their eyes as I pull it. My n is still relatively low finishing residency, but haven't had a single laryngospasm yet.
Click to expand...

where is the data on the above?
 
jwk said:
Never had someone cough or gag on an LMA? Hmmmm. I usually take mine out deep so it's not a problem, and when I take them out awake, MOST of the time they don't really cough much - but they can and do cough and gag on them, and I've seen two bitten in half.

You're lucky you can take yours to PACU with an LMA in. Our nurses would have a friggin cow.
Click to expand...

Agreed, all my on mine are pulled deep. Had a couple times where they coughed, altering the position of the LMA. Couldnt pull it because the had a clenched jaw but couldnt ventilate either. Had to put them back down and added 15 minutes to my wake up.

Also could not bring it to pacu without writing a protocol first😡
 
I agree with those that treat it as a supraglotyic airway device similar to an oral airway. It's basically a better oral airway but similarly stimulating of the deep oropharynx triggering gag reflexes. We put oral airways in at low macs and remove them etc w little incidence of causing laryngospasm. As long as I suction well before removing I take it out whenever. Spit/blood is what will touch the cords and trigger laryngospasm in adults, most are not sensitive to much else in my experience. Kids are much more sensitive and prone to laryngospasm from milder stimulation so I pull it deep or awake not in-between. I think it's fine to transport to pacu with an lma, it's a super oral airway, what's the big deal...
 
PL32 said:
Spit/blood is what will touch the cords and trigger laryngospasm in adults
Click to expand...

I'm not so sure about this since i saw an experienced anesthesiologist skip the suctioning part without having a higher incidence of spasm. 😕
 
dhb said:
I'm not so sure about this since i saw an experienced anesthesiologist skip the suctioning part without having a higher incidence of spasm. 😕
Click to expand...

I've never suctioned the mouth prior to LMA removal unless it's a bloody nasal case, or I otherwise expect mucho secretions, like an edentulous patient.

Can someone tell me why the ones with dentures always seem to drool the most?
 
Bertelman said:
I've never suctioned the mouth prior to LMA removal unless it's a bloody nasal case, or I otherwise expect mucho secretions, like an edentulous patient.

Can someone tell me why the ones with dentures always seem to drool the most?
Click to expand...

Curious, what types of nasal cases are you doing with LMAs? Sounds risky to me but I'm interested to hear what you are doing.

Just about finished with residency here, and I must admit that I am somewhat ambivalent towards LMAs. Great rescue devices, obviously. As primary airway management, my experience has been that they tend to go either very well or very badly. In fact, I almost lost an airway on an obese guy they other day when he obstructed with the LMA in, eventually laryngospazzed during attempts at repositioning, and then was a subsequent impossible laryngoscopy. My future practice will be to intubate patients in whom I think definitive rescue management after LMA placement may be difficult. Is this a heuristic bias? You bet your ass...
 
septoplasty, sometimes endoscopic sinus stuff at the ASC. Flex LMA works pretty well. I suck the hell out of those before removing.

Maybe the running thought is that those sinus suffering people challenge their larynx daily with the gunk dripping down, thus are at lower risk of spasm. I'm just talking out my ass, but it sounds good.



I think I've read here before of some folks doing tonsils with an LMA.
 
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nycitygas said:
Great info. I was wondering as well, how many of you guys deflate the lma before putting it in? Is that standard practice (I do and have noticed a better fit with but got a questionable look from attending last week doing it)
Cheers
Click to expand...

I never deflate LMA.
 
trinityalumnus said:
What next step did you take?
Click to expand...

Prior to the larngoscopy I had tried to break the spasm with propofol but couldn't move air with LMA. I ended up taking the LMA out and tried two hand mask with oral airway, then I gave him intubating dose of sux and was able to ventilate with two hands and an oral airway after he relaxed. We ended up waking him up...
 
Agree with those who said it's the world's greatest oral airway. Why take it out and replace it with an standard OA and then mask the patient? Makes no sense. I leave the agent alone until dressing are on (with 100% o2), turn agent off, move patient to stretcher and transport to PACU with the LMA in situ (usually). As soon as they show signs of rejecting it (tonguing it out, etc.) then I pull it. Usu before I've finished giving report.

Like others also: I insert at about 2/3 or 3/4 inflated (it seems to help prevent the tip from "flipping back") and pull it out fully inflated - it is not passing through any structures (e.g. vc's) and seems to "raft" out secretions.

As Bertleman said, only suction for those bloody ENT cases when using flexies.

cheers,
dog
 
Dogdaze said:
Agree with those who said it's the world's greatest oral airway. Why take it out and replace it with an standard OA and then mask the patient? Makes no sense. I leave the agent alone until dressing are on (with 100% o2), turn agent off, move patient to stretcher and transport to PACU with the LMA in situ (usually). As soon as they show signs of rejecting it (tonguing it out, etc.) then I pull it. Usu before I've finished giving report.

Like others also: I insert at about 2/3 or 3/4 inflated (it seems to help prevent the tip from "flipping back") and pull it out fully inflated - it is not passing through any structures (e.g. vc's) and seems to "raft" out secretions.

As Bertleman said, only suction for those bloody ENT cases when using flexies.

cheers,
dog
Click to expand...

Well, it would be good at directing vomit to the lungs even after turning lateral, while also preventing adequate suction... maybe not the best oral airway.
 
GypsySongman said:
Well, it would be good at directing vomit to the lungs even after turning lateral, while also preventing adequate suction... maybe not the best oral airway.
Click to expand...

With the ability to drop a suction cath down the airway, I would think it's much easier to suction trachea with an LMA v. oral airway.
 
Idiopathic said:
where is the data on the above?
Click to expand...

there are no studies directly comparing a simple guedel vs LMA for the incidence of laryngospasm. however, this study demonstrated a cuffed guedel is roughly equivelant to an LMA in incidence of laryngospasm. make a slight inference.

Anesthesiology. 1998 Apr;88(4):970-7.
A randomized controlled trial comparing the cuffed oropharyngeal airway and the laryngeal mask airway in spontaneously breathing anesthetized adults.

Greenberg RS, Brimacombe J, Berry A, Gouze V, Piantadosi S, Dake EM.
Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA. [email protected]
 
Gypsy, I'm with Bertleman on this one. Whatcha gonna do if they vomit with OA in place? same thing I'd do with LMA in place.

Yes, have done tonsils with LMA, but only during residency. had an ENT who preferred them. He was very very "dry", and spent a 5 minute (yes a full 5 minutes by the clock) timeout to ensure no bleeding, by the time i got the airway back, it was a dream...

current ENTs want no part however,
 
Dogdaze, I have never actually practiced this. Do you bag them on the way to the PACU or do they do well enough with just a LMA and spontaneously breathing room air? I would guess they would do fine without any bagging, but just was curious what your practice is. I like to pull the LMA either deep or awake depending on my mood that day. I like to immediately put on a face mask and watch for misting of the mask and chest movement to make sure they are breathing if they are not conversant. My only problem with leaving the LMA for transport to the PACU without any ambu, is my only monitor of possible ventilation is chest rise since I wouldnt have the constant misting of the face mask to reassure me that my patient is breathing.
 
If you need the misting to verify ventilation, just hang an oxygen mask on the end of the LMA. You can also hold your hand near the end and feel air movement with exhalation.

- pod post #750
 
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MeaCulpa said:
My only problem with leaving the LMA for transport to the PACU without any ambu, is my only monitor of possible ventilation is chest rise since I wouldnt have the constant misting of the face mask to reassure me that my patient is breathing.
Click to expand...


I'm picturing a small piece of tape, affixed to the plastic adapter on the LMA, then folded onto itself to hang just into the lumen of the LMA tube. It should flap in and out with inhalation. Maybe even one of those small Post-It flags.

Try it this week. Get back to me. I've got some friends that can lay out a patent. Shouldn't cost more than 10c to manufactuer per item, but we'll charge $10 per patient use. It will be disposable, of course.

We'll be trillionaires. We'll sell before the inevitable lawsuits.
 
Colba55o said:
What is the current opinion on when the appropriate time is to pull out an LMA
Click to expand...


Sometime between when you hear the surgeon say, "we'll be closed in 10 minutes" and when you walk out the door to go to the PACU. I don't think it matters beyond that.

Actually, the best time is right after you put it in...decide you want to relax, so you pull it out, throw it away, and put a damn tube in. (A staff used to tell me that two things close during a D&C when using an LMA after they stick something in there - first their legs close, then the vocal cords.)

Stupid LMA's.....(you haven't lived until you have a young patient who you think is deep enough, actually sit up after incision)

Although my brother always says, the best spinal is an LMA. HAHA. that's probably true...
 
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