Hong Kong Journal of Emergency Medicine

Role of laryngeal mask airway in emergency department and pre-hospital

environment
FKC Chu

LMA and Intubating LMA (LMA-Fastrach) have been widely used by anesthesiologists in operation theaters
and have achieved great success. Its use in the emergency department and pre-hospital setting by EMS has
recently been proven to be very successful. It is also a very useful tool in providing a quick airway in case of
failed intubation and failed ventilation situations. In this article, some of its use in emergency departments
and pre-hospital setting are discussed. (Hong Kong j.emerg.med. 2003;10:57-62)
Keywords: Emergency department, laryngeal mask airway

Introduction
The Laryngeal Mask Airway (LMA) was introduced
by a British anesthesiologist Archie Brain in the 1980s.1
However it has only been used in Emergency Medicine
and pre-hospital setting recently. It was initially
designed to bridge the gap between facemask and
endotracheal tube. It provides a better airway than
the facemask with less dead space. On the other hand,
it does not require neuromuscular blockade or
laryngoscopy for placement. It is also better tolerated
than intubation. Thus, it has gained widespread
popularity and is being extensively used in patients
undergoing general anesthesia. More recently, it has
become a tool for difficult or failed intubations in the
ASA (American Society of Anesthesiologists) Difficult
Airway Management Algorithm.2
With the modification of the usual Laryngeal Mask
Airway, a new prototype of LMA-Intubating LMA
(ILMA or LMA-Fastrach) was developed. It offers
broader applications in the emergency department and

Correspondence to:
Chu Kin Chiu, Francis, MBBS(HK), MRCP(UK)
Queen Elizabeth Hospital, Accident and Emergency Department,
30 Gascoigne Road, Kowloon, Hong Kong
Email: chu00338@i-cable.com

pre-hospital setting.3 It is designed to provide a quick

airway and to assist intubation.
This article reviews the development, advantages and
disadvantages of Laryngeal Mask Airway (LMA) and
Intubating LMA and particularly its role in the
emergency department and pre-hospital environment.

History
The LMA was invented by a British anesthesiologist
Dr. A.I.J. Brain in London in 1981. By examining
postmortem specimens of the larynx, Brain noted
that an airtight seal could be achieved around the
laryngeal inlet by an inflated cuff in the
hypopharynx. Prototype LMA was developed from
molds made from Plaster of Paris of cadaveric
pharynx and the Goldman dental mask. After years
of developments, the first LMA was commercially
available in Britain in 1988 and was approved by
the FDA in US by 1992. Nowadays, commercially
available LMA is manufactured from medical-grade
silicon and consists of an obliquely cut tube
mounted into the concave central part of an oval
mask. (Figure 1) Also, different sizes and types of
LMA, including the Classic and the intubating
LMA (Fastrach, as shown in Figure 2) are available.

58

Hong Kong j. emerg. med.

Vol. 10(1) Jan 2003

Figure 1. Laryngeal mask airway.

Figure 2. Intubating laryngeal mask airway.

Insertion of LMA

patients, insertion of an LMA required a mean of 39s

with a mean of 1 attempt/patient success as compared
with 206s for an ETT with 2.2 attempts/patient
success. No one failed to insert an LMA but 10 out of
19 could not intubate.

Preparation
Before every use, the LMA should be checked for
cracks and whether it has been sterilized as LMA is a
reusable device. The cuff should be deflated so that
the tip forms a flat leading edge. Then the convex
surface, but not the concave side of the LMA should
be lubricated. Lubricating the concave side may lead
to aspiration of lubricant, resulting in coughing and
laryngospasm.
Although the LMA can be inserted under topical
anesthesia, it is normally inserted under general
anesthesia. Correct insertion requires an adequate level
of anesthesia to obtund pharyngeal reflexes. In contrast
to endotracheal intubation, muscle relaxants are
unnecessary. Intravenous induction agents, together
with opioids (such as fentanyl or alfentanyl) are
adequate for insertion in most circumstances.
Among all the available induction agents, Propofol in
the dose of 2.0-2.5 mg/kg seems to be the best for
insertion of LMA.

Techniques of insertion
Unlike intubation, insertion of LMA can be achieved
in a high proportion of patients with little practice.
Therefore LMA can be used widely in emergency and
pre-hospital setting. In one study,4 comparing success
and time to airway management by paramedics and
respiratory therapists in anesthetized and paralysed

Proper insertion technique is necessary for optimal

placement and poor technique may lead to the loss of
airway.
Standard insertion technique is described in the LMA
instruction manual and is summarized below. Following
adequate amount of induction agent and narcotics until
jaw relaxation is achieved, place the patient in the
"sniffing the morning air position" with neck flexed and
head extended if cervical spine immobilisation is not
required. Place the lubricated LMA into the mouth, press
it back against the hard-palate with the index finger to
flatten the LMA.
Now, it is important to check that the rim of the
LMA does not fold back on itself at this stage. Then
slide the LMA behind the tongue and into the
pharynx until a definite resistance is felt to indicate
that it has reached its final location. The cuff
should then be inflated. During inflation, the LMA
should be free to move and it will invariably centre
itself over the laryngeal opening.
Confirmation of proper position can be achieved by
end-tidal CO2 detection, or by observing movement
of reservoir bag. A black line printed along the
posterior surface of the LMA tube gives a visual
confirmation of the correct position.

Chu/Role of laryngeal mask airway

Clinical use of LMA

(1) LMA as an airway for operation:
It is primarily designed as an alternative to simple
facemask for protected and assisted ventilation
i n c e r t a i n s u r g i c a l p ro c e d u re s i n w h i c h
endotracheal intubation is not required.
A further advantage is that the anesthesiologist
can free his hand for other task, such as drug
administration.

(2) LMA as an emergency airway:

Recently, in algorithms published by both the
American Society of Anesthesiologists and the
European Resuscitation Council, the LMA is
considered a primary option for the management
of difficult airway and failed airway patients. 2
(Figure 3)
Although endotracheal intubation is the most
secure way to control and maintain the airway,
it can sometimes be very difficult, even in
experienced hands. Maintaining ventilation with
bag-valve mask can also become difficult
especially in edentulous or bearded patients.
Moreover, maintaining ventilation using bag-

59

valve mask often requires two hands to make a

tight seal and LMA, in this circumstance, can
free the resuscitator for injection or chest
compression.
Literature review showed only one reported case
of failure to ventilate in a patient with LMA. 5
Some studies have shown that LMA has been
used successfully by physicians, nurses and
paramedics, regardless of patient's position.
The LMA can also be placed in patients with
fixed neck deformity and limited mouth opening
as a result of facial burn.6

(3) To facilitate intubation through LMA:

A 6-mm internal diameter endotracheal tube
(ETT) can be passed through the tube of size
3 and 4 LMA. If the LMA is well lubricated and
correctly positioned, the ETT can be inserted
blindly through the aperture into the larynx.
Successful intubation rate can be up to 90%.
However, after introduction of the special
Intubating LMA, blind intubation through LMA
becomes less common.
A size 6 ETT may be too small for an adult male,
the insertion of a larger ETT can be facilitated
by using the gum-elastic bougie. A gum-elastic
bougie is inserted through the LMA and act as a
guide-wire.7 With the removal of the LMA, larger
size ETT can be inserted into the larynx through
the bougie.
In order to improve accuracy, the ETT can be
mounted onto the fiberoptic brochoscope which
is then passed through the LMA.8 This technique
allows the vocal cord to be visualized. It avoids
blind intubation, and increases the success rate.
It is useful in paediatric patients since ILMA is
not available in paediatric patients.

(4) Resuscitation:
Figure 3. An algorithm showing the use of LMA in difficult
and failed airway management.

Besides acting as an immediate airway, LMA can

also be used as a conduit for administration of

Hong Kong j. emerg. med.

60

medications during resuscitation. In one study,

considerable amount of adrenaline was found in
pulmonary tree after it is injected down a seated
LMA in cadaver.9 However, similar results are not
demonstrated in other studies. 10 Thus, it is
suggested that during resuscitation, in those
patients who have no airway nor venous access,
injection of medication down the LMA may be
worth the attempt, but the outcome is not as
reliable as via the ETT.
Advantages of using LMA in ED
The LMA can be easily placed and provides a
quick and adequate airway with relatively few
complications. It is easy to learn. Thus it can be
used by physicians, nurses, and paramedics to
provide quick airway during resuscitation,
especially for those who are inexperienced in
intubation or in cases of failed intubation. In a
study concerning pre-hospital airway management
by ambulance officers in Australia, the overall
success rate of LMA insertion was 80%. 11
It is better than bag-valve mask since one can
free his hand for other resuscitation process and
it is more secure than the bag-valve mask.
In an unanticipated difficult intubation, LMA
can provide a temporary airway to prevent
desaturation, while one can buy time to call for
assistance, perform surgical airway or re-intubate
through the LMA with or without gum-elastic
bougie or fiberoptic bronchoscope.
LMA can be placed even if the patient has
fixed neck deformity, or needs cervical spine
immobilisation, or is in a prone or lateral
position. In trauma victims who are trapped,
and those who need to secure the air way
quickly, LMA can provide a better airway than
facial mask, and under this unfavourable
occasion, it is rather difficult for paramedics
or even emergency physicians to intubate the
victims.

Vol. 10(1) Jan 2003

Complications of LMA
Complications are rare with its use in the
operation room. Unlike the ETT, it does not
protect from aspiration of gastric content and
other secretion. Laryngospasm occurs when the
patient is not deepened enough during insertion.
These are not actually significant in patients
undergoing elective surgery since most of them
have been fasted for an adequate period before
operation. Brimacombe conducted a metaanalysis of the published literature in 1995 and
found that the incidence of aspiration was only
2/10000 with LMA 12 which was similar to that
recorded during general endotracheal anaesthesia.
However, it is a major problem in our patients
in Emergency Department. Most of them have
not been fasted, thus regurgitation and aspiration
can be a serious problem. Like the rapid sequence
induction, cricoid pressure should be exerted and
maintained continuously after placement to
reduce regurgitation and aspiration of gastric
contents in patients who are at high risk of
aspiration like (1) those after prolonged bagging,
(2) pregnancy, (3) morbid obesity, and (4) those
with upper gastrointestinal bleeding.
Positive pressure ventilation, although possible
in LMA if the pressure does not exceed 20 cm
H2O, 13 is relatively contraindicated. It leads to
air leak and promotes gastric distention and
aspiration. Therefore, it may not be suitable in
situations of severe asthma or acute pulmonary
oedema.
Misplacement of LMA will lead to obstruction.
Improper insertion of LMA may fold the
epiglottis and thus obstruct the airway. Over
inflation of the LMA cuff may impose pressure
on the hypopharynx and could cause pressure
necrosis. Compression on nerve can result in
dysarthria, which is usually transient. Tongue
cyanosis has been reported due to occlusion of
the lingual artery by LMA. 14

Chu/Role of laryngeal mask airway

The Intubating Laryngeal Mask Airway (ILMA)

Laryngeal Mask Airway has provided a quick
airway for patients with difficult intubation with
great success. However, for patients seen in
emergency department (ED) and Emergency
Medical Services (EMS), a definite airway is
usually preferred. By modification of the LMA,
a new prototype has now been developed the
Intubating LMA (ILMA).
ILMA consists of a short, anatomically curved,
rigid, stainless steel shaft that follows the oral,
pharyngeal, and laryngeal axes of the airway,
allowing facile alignment of the mask with the
glottis. It has a metal handle that aids in insertion
and manipulation of the device. There is a Vshaped ramp that guides the ETT through the
mask aperture directly and a moveable but rigid
epiglottis elevating bar that lifts the epiglottis
out of the way of the advancing ETT.
It is particularly useful in the ED and EMS
setting when compared to the standard LMA as
it can assist intubation, minimise head and neck
movement, and therefore particularly useful in
patients with cervical spine injury.

Insertion technique
The insertion of ILMA is different from that of the
usual LMA in several ways. 15 The technique involve
the following steps:
1. Keep the patient's head in neutral position, rather
than in slightly extension.
2. Hold the intubating LMA by its handle and
position the mask tip flat against the hard palate
just inside the mouth and immediately posterior
to the upper central incisors. Then slide the mask
tip slightly back and forth to coat the hard palate
with lubricant.
3. Slide the mask backwards, following the curve of
the tube with fingers of the other hand to open
the mouth slightly.

61

4. Swing the entire device downward into place, then

inflate and secure. Indications that the ILMA is
correctly positioned include (i) the ability to
generate an airway pressure of 20 cm H 2O, and
(ii) the ability to ventilate manually.
5. Pass the appropriate-sized wire-reinforced tube
through the ILMA with lubricants.
6. If resistance is encountered, it is most likely due
to the downfolding of the epiglottis or lodging of
the tube against the vestibular wall. Rotating the
ETT bevel may solve the problem.
7. If difficulty is encountered, it is possible to try
smaller sized ETT or to guide the ETT with the
help of a fiber-optic bronchoscope.
8. Finally, the ILMA can be removed or can be left
behind after the ETT is inserted.
A number of studies have shown that ILMA has a high
success rate but the learning curve is somewhat steeper
than the usual LMA.16
Case reports have also demonstrated the successful use
of ILMA in patients with cervical spine injury
undergoing rapid sequence induction.17
Thus, for emergency department staff and emergency
medical service providers, Intubating LMA offers an
attractive option for emergency airway management
in the "cannot intubate and cannot ventilate scenario".
It can provide an emergency airway even though
intubation may not be achieved.
The ILMA should not be used for a prolonged
period once a definite airway is achieved since it
may result in pressure necrosis of the pharyngeal
mucosa.

Conclusion
The American Society of Anesthesiology has
introduced the use of LMA and the ILMA as a tool
for emergency airway management in situations when
one "cannot intubate or cannot ventilate".

62

Hong Kong j. emerg. med.

Both the LMA and the newer ILMA are easy to use
and require only little training to master the technique.
They are ver y suitable for use in emergency
department and by pre-hospital medical service
providers for patients with difficult airway.

aided by the laryngeal mask airway. Anaesthesia 1989;

44(12):1015.
Silk JM, Hill HM, Calder I. Difficult intubation and
the laryngeal mask. Eur J Anaesthesiol 1991;Suppl 4:
47-51.
Challiner A, Rochester S, Mason C, Anderson H,
Walmsley A. Spread of intrapulmonary adrenaline
administered via the laryngeal mask. Resuscitation
1997;34:193.
Alexander R, Swales H, Pickford A, Smith GB. The
laryngeal mask airway and the tracheal route for drug
administration. Br J Anaesth 1997;78(2):220-1.
Grantham H, Phillips G, Gilligan JE. The laryngeal
mask in pre-hospital emergency care. Emerg Med 1994;
6:193-7.
Brimacombe JR, Berry A. The incidence of aspiration
associated with the laryngeal mask airway: a metaanalysis of published literature. J Clin Anesth 1995;7
(4):297-305.
Asai T, Morris S. The laryngeal mask airway: its features,
effects and role. Can J Anaesth 1993;40(10):930-60.
Wynn JM, Jones KL. Tongue cyanosis after laryngeal
mask airway insertion. Anesthesiology 1994;80(6):
1403.
Brain AIJ, Verghese C. LMA-Fastrach instruction
manual. San Diego, CA: Laryngeal Mask Co., Ltd.;1998.
Baskett PJ, Parr MJ, Nolan JP. The intubating laryngeal
mask. Results of a multicentre trial with experience of
500 cases. Anaesthesia 1998;53(12):1174-9.
Schuschnig C, Waltl B, Erlacher W, Reddy B, Stoik
W, Kapral S. Intubating laryngeal mask and rapid
sequence induction in patients with cervical spine
injury. Anaesthesia 1999;54(8):793-7.

References
1. Brain AI. The laryngeal mask: a new concept in airway
management, Br J Anaesth 1983;55(8):801-5.
2. Practice guidelines for management of the difficult
a i r w a y. A r e p o r t by t h e A m e r i c a n So c i e t y o f
Anesthesiologists Task Force on Management of the
Difficult Airway. Anesthesiology 1993;78:597-602.
3. Rosenblatt WH, Murphy M. The intubating laryngeal
mask: use of a new ventilating-intubating device in the
emergency department. Ann Emerg Med 1999;33(2):
234-8.
4. Reinhart DJ, Simmons G. Comparision of placement
of the laryngeal mask airway with endotracheal tube by
paramedics and respiratory therapists. Ann Emerg Med
1994;24(2):260-3.
5. Patel SK, Whitten CW, Ivy R 3rd, Macaluso A, Pennant
J. Failure of the laryngeal mask airway: an undiagnosed
laryngeal carcinoma. Anesth Analg 1998;86(2):438-9.
6. Thomson KD, Ordman AJ, Parkhouse N, Morgan BD.
Use of the Brain laryngeal mask airway in anticipation
of difficult tracheal intubation. Br J Plast Surg 1989;
42(4):478-80.
7. Chadd GD, Ackers JW, Bailey PM. Difficult intubation

8.
9.

10.
11.
12.

13.
14.
15.
16.
17.

Vol. 10(1) Jan 2003