![]() ![]() However, failure rates can be as high as 40%, and endotracheal intubation is best facilitated under direct visualization using a flexible bronchoscope. The LMA Fastrach has a higher rate of intubation success compared to the standard 1 generation and is designed for blind intubation using the company’s proprietary endotracheal tube. Those devices do not have aperture bars at the cuff end and usually have higher seal pressures than the original LMAs that are still frequently used. Once the cuff is inflated with the designated amount of air and placement is checked by attaching a bag mask and delivering breaths, assessing breath sounds, and/or using continuous waveform capnography or, at a minimum, a CO 2 detector device.Įndotracheal intubation can be achieved by inserting the endotracheal tube (ETT) through most second-generation LMAs. This volume may need to be adjusted to optimize the seal and minimize the air leak. The collar should then be inflated with approximately 20 mL for number three, 30 mL for number four, and 40 mL for number five. The LMA is introduced behind the tongue with backward pressure using the index finger, pressing the device against the hard palate until it is completely inserted. Then use the other hand to push the LMA until some resistance is felt and it can go no further. Otherwise, a jaw thrust may be performed to facilitate passage. When there is no risk of neck damage, the neck is extended in a sniffing position. Lubricate both sides of the device with a water-soluble lubricant. The cuff should be inflated and then completely deflated to ensure the cuff is not folded, pressing firmly on the flat surface. Prior to insertion, the device should be placed on a flat surface. It may be used in patients of all ages, from small infants to adults. The i-Gel also allows for the passage of standard endotracheal tubes. They are made from a gel-like substance, which may be easier to insert because there is no cuff to inflate. The I-Gel devices are unique in that they have a pre-shaped non-inflatable cuff. This device is designed for use with specialized endotracheal proprietary tubes made and packaged with the ILMA. It is available in both reusable and disposable forms and has a handle designed to allow for optimal positioning and a bar designed to elevate the epiglottis out of the way to facilitate intubation. The LMA Fastrach, also called the ILMA, is specifically designed to facilitate blind intubation. Newer second-generation LMAs are now available and provide for higher seal pressures due to improved seal material or design, have no aperture bars, allow for easier intubation using regular endotracheal tubes, and provide a gastric access port to vent or aspirate gastric contents. Those first-generation devices are still commonly used for routine cases due to their low cost and they have low complication rates. However, that design makes intubation through that device much more challenging. The original LMA design has crossbars over the aperture designed to prevent passive herniation of the epiglottis into the opening. ![]() Several configurations are available from multiple vendors. While the original LMA was a multi-use device, cleaning requirements, and high cost have steered providers towards less costly, single-use LMAs. They consist of a tube attached to an inflatable, elliptical cuff designed to cover the supraglottic area, facilitating an open airway passage and allowing for either spontaneous or positive pressure ventilation. LMAs come in many forms and configurations. Small mandibular spaces, assessed by shortened thyromental distance, are associated with the difficult use of extraglottic devices due to the position of the tongue. Distortion or disruption of the airway from the midline makes the device less likely to seat properly. Obese patients may have redundant tissue, making it more difficult to seat the device in place, and the increased ventilatory pressures required in obese patients may increase the likelihood of a leak. Patients with upper or lower airway obstruction due to a tumor or foreign body may make passage of or ventilation through the device difficult or impossible. Restriction refers to both increased airway resistance - extraglottic devices have lower leak pressures than endotracheal tubes - as well as restricted mouth opening insufficient to allow for the passage of the device. RODS stands for Restriction, Obstruction/Obesity, Disrupted or Distorted anatomy, and Short thyromental distance. The mnemonic RODS can be used to predict difficulty in either placing an extraglottic device or in providing adequate gas exchange through one. Supraglottic devices, like the LMA, are designed to be inserted blindly through the mouth and into the hypopharynx to seal around the glottic opening allowing for ventilation. ![]()
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