LARYNGEAL MASK AIRWAY COURSE - cont'd info

Indications for a laryngeal mask airway placement

  • GCS < 8 in the setting of trauma
  • Persistent combativeness refractory to medications in the setting of trauma
  • Major skin burns of 40% or more of body
  • Severe smoke inhalation
  • Moderate-severe facial or oropharyngeal burn

Considerations for laryngeal mask airway placement

  • May not be able to ventilate patients with stiff lungs 

   – ARDS or pulmonary fibrosis

  • Poor option for morbidly obese patients
  • All of these conditions will make oral intubation difficult and increase the need for a surgical airway

Indications for Intubation

  • Unable to protect airway
  • Hypercapneic respiratory failure
  • Hypoxic respiratory failure
  • Cardiac arrest
  • Need to maintain hyperventilation

– Closed head injury

Complications of laryngeal mask airway placement

  • Aspiration pneumonitis
  • Inability to ventilate patients with morbid obesity or who have poorly-compliant lungs (ARDS or pulmonary fibrosis)

Considerations for Oral Intubation

  • Tracheal fracture or disruption
  • Inability to extend neck

– C-spine fracture requires cervical immobilization
– Fused neck: consider fiberoptic oral intubation

  • Uncontrolled oropharyngeal hemorrhage
  • Mandibular fracture, trismus, or limited jaw opening

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Equipment for laryngeal mask airway placement

LMA sizes Weight Cuff Volume*
3 30-50 kg 20 mL
4 50-70 kg 30 mL
5 70-100 kg 40 mL

 

  • Appropriately sized LMA tube
  • 50 mL Luer-lok syringe
  • Bag-valve mask
  • EtCO2 detector

Proper positioning and technique for laryngeal mask airway placement

  • Place patient in supine postion
  • Introduce LMA along the curve of the palate using index finger to push the LMA cuff the full length of the index finger
  • Grasp the LMA shaft and push until the LMA is firmly in place
  • Inflate the cuff

Options for Difficult Airway Management

What are my options in CVCI?

  • Airway Adjuncts

–  Intubating Stylet

  • Video Laryngoscopy
  • Intermediate Airway

– LMA
– Combitube
– King Tube

  • Surgical Airway

– Needle Cricothyroidotomy
– Surgical Cricothyroidotomy

Anesthesiology. 2013; 118(2):251-270

Options for the Can’t Ventilate Can’t Intubate scenario

Coding for endotracheal intubation
31500 – endotracheal intubation

Can’t Ventilate Can’t Intubate

Anticipate and Avoid

– Delay until help arrives
– Awake Intubation
– Video Laryngoscopy

Plan and Proceed

– Intubation Adjuncts
– Video Laryngoscopy
– Intermediate Airway
– Surgical Airway

Anesthesiology. 2013; 118(2):251-270