Overview

The laryngeal mask airway (LMA) is a supraglottic airway device developed by British Anesthesiologist Dr.
Archi Brain. It has been in use since 1988. Initially designed for use in the operating room as a method of
elective ventilation, it is a good alternative to bag-valve-mask ventilation, freeing the hands of the provider with
the benefit of less gastric distention.[1] Initially used primarily in the operating room setting, the LMA has more
recently come into use in the emergency setting as an important accessory device for management of the
difficult airway.
The LMA is shaped like a large endotracheal tube on the proximal end that connects to an elliptical mask on
the distal end. It is designed to sit in the patients hypopharynx and cover the supraglottic structures, thereby
allowing relative isolation of the trachea.
The LMA is a good airway device in many settings, including the operating room, the emergency department,
and out-of-hospital care, because it is easy to use and quick to place, even for the inexperienced provider.[2, 3, 4] A
success rate for placement of a LMA of nearly 100% occurs in the operating room. A lower rate of achievement
for LMA placement may be expected in the emergency setting.[5] Its use results in less gastric distention than
with bag-valve-mask ventilation, which reduces but does not eliminate the risk of aspiration. [6, 7] This may be
particularly pertinent in patients who have not fasted before being ventilated.
Laryngeal mask airways come in several types.

The LMA Classic is the original reusable design.

The LMA Unique is a disposable version, making it ideal for emergency and prehospital settings. [8]
The LMA Fastrach, an intubating LMA (ILMA), is designed to serve as a conduit for intubation.
Although most LMA designs can serve this purpose, the LMA Fastrach has special features that increase the
rate of successful intubation and do not limit the size of the endotracheal tube (ETT). These features include
an insertion handle, a rigid shaft with anatomical curvature, and an epiglottic elevating bar designed to lift the
epiglottis as the ETT passes.
The LMA Flexible has softer tubing. It is not used the in the emergency setting.
The LMA ProSeal has the addition of a channel for the suctioning of gastric contents. It also allows for
50% higher pressures without a leak. However, it does not permit blind intubation and is not currently used in
the emergency setting.
The LMA Supreme, which is a newer design, is similar to the ProSeal and has a built-in bite block. [8]
Another newer design is the LMA CTrach, which inserts like the LMA Fastrach and has built-in
fiberoptics with a video screen that affords a direct view of the larynx.

Indications
Elective ventilation

The laryngeal mask airway (LMA) is an acceptable alternative to mask anesthesia in the operating
room.

It is often used for short procedures when endotracheal intubation is not necessary. [1]
Difficult airway

After failed intubation, the LMA can be used as a rescue device.

In the case of the patient who cannot be intubated but can be ventilated, the LMA is a good alternative
to continued bag-valve-mask ventilation because LMA is easier to maintain over time and it has been shown
to decrease, though not eliminate, aspiration risk. [6, 7]

In the case of the patient who cannot be intubated or ventilated, a surgical airway is indicated and
should not be delayed. However, if the LMA is at hand, it can easily be attempted quickly, while an assistant
simultaneously prepares for cricothyroidotomy. [5]
Cardiac arrest

The 2005 American Heart Association guidelines indicate the LMA as an acceptable alternative to
intubation for airway management in the cardiac arrest patient (Class IIa). [6]

This may be particularly useful in the prehospital setting, where emergency medical technicians
typically have less experience with intubation and lower success rates. [9]
Conduit for intubation

The LMA can be used as a conduit for intubation, particularly when direct laryngoscopy is
unsuccessful.

An ETT can be passed directly through the LMA or ILMA. Intubation may also be assisted by a bougie
or fiberoptic scope.
Prehospital airway management

The LMA is useful in the prehospital setting not only for patients in cardiac arrest but also for managing
a difficult airway.

In patients in whom positioning or prolonged extrication does not allow for endotracheal intubation, the
LMA can be inserted and allow for successful airway management until a definitive airway can be
established. [6]

The widespread use of LMA in the prehospital setting in Japan for cardiac arrest has shown it to be an
effective and relied upon method for establishing emergency airways. [10]
Pediatric use

Laryngeal mask airways are available in a range of pediatric sizes.

Contraindications
Absolute contraindications (in all settings, including emergent)

Cannot open mouth

Complete upper airway obstruction
Relative contraindications (in the elective setting)

o
o
o
o
o

Increased risk of aspiration

Prolonged bag-valve-mask ventilation
Morbid obesity
Second or third trimester pregnancy
Patients who have not fasted before ventilation
Upper gastrointestinal bleed
Suspected or known abnormalities in supraglottic anatomy
Need for high airway pressures (In all but the LMA ProSeal, pressure cannot exceed 20 mm H 2 O for
effective ventilation.)

Anesthesia
Sedation

Laryngeal mask airway (LMA) insertion is facilitated by sedation.

Propofol (Diprivan) or midazolam (Versed) are acceptable choices. [3]
For elective ventilation in the operating room, less anesthesia is typically required for insertion and
maintenance of the LMA than for endotracheal intubation. [3]

In the emergency setting, the patient is often obtunded or unconscious, and further sedation may not
be necessary for LMA insertion.

The risk of inadequate sedation is triggering laryngospasm.

For more information, see Procedural Sedation.

Paralysis is not necessary for LMA insertion and maintenance.
Movement and coughing upon insertion should be particularly avoided in patients who are at risk for cervical
spine injuries; therefore, adequate anesthesia is particularly important in these patients.
Children may require deeper anesthesia.

Equipment

Laryngeal mask airway (LMA), shown below

courtesy of LMA North America.

America.

LMA Classic. Image

LMA Fastrach. Image courtesy of LMA North

Appropriately sized syringe for cuff inflation (included in LMA kit)

Water-soluble lubricant (included in LMA kit)
Bag-valve mask
Oxygen source
Yankauer suction device
End-tidal carbon dioxide (E T CO 2) detector
Intubation equipment and a cricothyroidotomy kit (These items should be close at hand.)

Positioning
The optimal head position for insertion of the laryngeal mask airway (LMA) is sniffing position. [3]
The optimal head position for insertion of the intubating laryngeal mask airway (ILMA) is neutral position. [3]

Technique
Preparation

Preoxygenate the patient with 100% oxygen via a nonrebreather mask, as time allows.
Choose the appropriate size of laryngeal mask airway (LMA).
Check the LMA cuff for leaks.
Deflate the cuff of the LMA completely against a flat surface.
Apply a water-soluble lubricant generously to the posterior surface of the mask.
Administer sedation when indicated.
Position the patient.

Cricoid pressure

Cricoid pressure is intended to reduce the risk of aspiration and should be maintained, especially in
patients who have not fasted, until the airway is secured.
Decreased rates of successful insertion, however, have been seen with application of cricoid
pressure. [2, 4, 3]
Cricoid pressure may need to be released in order to properly position the LMA.

Insertion of the LMA

Hold the LMA like a pen, with the index finger of the dominant hand at the junction of the mask and the

tube, as shown below.

Insertion of the LMA.
Slide the LMA along the hard palate, pushing it back against the palate as it is advanced toward the
hypopharynx, as in the image below. This prevents the tip from folding over on itself and reduces interference

from the tongue.

Insertion of the LMA.
Advance with gentle pressure until resistance is met.
If necessary, continue pressure on the tube with the nondominant hand to fully advance the LMA to its
proper position.
Once in place, inflate the cuff without holding the LMA to allow it to acquire its natural position.
Approximately 8 cm of the tube protrudes from the patients mouth.
The video below depicts LMA insertion.
Video demonstration, insertion of the LMA.

Insertion of the intubating laryngeal mask airway (ILMA)

Hold the ILMA by the handle.

Insert the mask into the patients mouth and push it back against the hard palate, as shown below.

Slide the mask backward, following the curve of the tube.

Swing the ILMA into place.
Inflate the cuff as with the LMA.

Insertion of the ILMA.

Insertion of the LMA ProSeal

Insert this model like the original LMA or attach it to a rigid insertion handle and insert it like an ILMA.

An alternate method is to use a bougie by placing it into the drainage tube and passing it deliberately
into the esophagus under direct laryngoscopy.
Advance the ProSeal over the bougie into position.

Confirming placement

Confirm the position of the LMA by auscultating bilateral breath sounds and an absence of sounds
over the epigastrium, observing chest rise with ventilation, and placing an E T CO 2 to look for color change.
Ensure that the vertical black line on the tube is at the patients midline.
Assess for ability to generate up to 20 cm of water pressure without a leak.

Intubating through the LMA and ILMA

Intubation through an intubating LMA such as the LMA Fastrach produces higher success rates than
intubating through a standard LMA (approximately 95% and 80%, respectively). [5]
The LMA Classic and LMA Unique limit the size of the endotracheal tube (ETT) that can be passed. A
6.0 ETT fits through LMA sizes 3 and 4. LMA sizes 5 and 6 accommodate an ETT up to 7.0.
Inspect the ETT and lubricate it well.
Pass it through the lumen of the LMA tube into the trachea until intubation is complete.

Confirm placement, as shown below.

A bougie or fiberoptic scope may be used to assist intubation.

The ETT is included with the LMA Fastrach, but a standard ETT can also be used.

Intubating through the ILMA.

Intubating through the ILMA.

Once the patient is intubated, the ILMA can be removed by deflating the cuff and passing it over the

tube using a stabilizer rod, as shown.

Removing the ILMA after intubation.

Removing the ILMA after intubation.

Intubation complete.

As an alternative to the standard insertion technique described above, there is evidence that laryngoscopeguided placement of the LMA results in higher initial success rates. [11]

Pearls

To optimize proper positioning, make sure the mask is completely deflated, with a smooth, welllubricated surface. Placing the mask face down on a flat surface such as a table helps achieve proper deflation.
If insertion is unsuccessful with cricoid pressure, release pressure and reattempt insertion.
If the initial laryngeal mask airway (LMA) placed does not result in a good seal, attempt the next larger
size. In general, if a patient is between sizes, choose the larger size.
When intubating through the ILMA, advance the endotracheal tube (ETT) until it is about to emerge
from the LMA (near the 15 cm mark). Then, lift up on the handle as the ETT is advanced into the trachea to
complete intubation. This is known as the Verghese maneuver after Dr. Chandy Verghese.
Although the LMA can be left in place after intubation, removing it promptly helps minimize upper
airway trauma.

Complications
Rare complications due to laryngeal mask airway (LMA) insertion occur in the operating room. The rate of
complications was 0.15% in a large study,[12] but the rate is likely to be higher in the emergency setting. Such
complications include the following:

o
o

Aspiration of gastric contents

Local irritation
Upper airway trauma
Pressure-induced lesions
Nerve palsies
Mild sympathetic response
Complications associated with improper placement
Obstruction

o
o

Laryngospasm
Complications associated with positive pressure ventilation
Pulmonary edema
Bronchoconstriction

[13]

Laryngeal Mask Airway Sizes

A table showing laryngeal mask airway size based on patient weight is included below.
Table. Laryngeal Mask Airway Size Based on Patient Weight (Open Table in a new window)
Weight, kg

Mask Size

Max Cuff Volume, mL

LMA Models

<5

Classic, Unique

5-10

1.5

Classic, Unique

10-20

10

Classic, Unique

20-30

2.5

14

Classic, Unique

30-50

20

Classic, Unique, Fastrach

50-70

30

Classic, Unique, Fastrach

70-100

40

Classic, Unique, Fastrach

>100

50

Classic