2. INTRODUCTION
ⶠDevices that are used to maintain the airway patency and provide
ventilation by placing just above the glottic opening.
ⶠThey sit outside the trachea and provide a hands free means of gas
tight airway.
ⶠStandard of airway management , filling the niche between
facemask and tracheal tubes.
ⶠDr
. Archie Brain developed LMA in 1982 as a modification of
Goldman dental mask with ETtube.
ⶠThe first commercially available supraglottic airway device was LMA-
Classic(1988).
3. CLASSIFICATION
ⶠBased on Generation:-
LMA
First Generation
ï¶Simple airway device.
ï¶Low pressure
pharyngeal seal
ï¶May ormay not protect
from aspiration.
ï¶Have no specific design
to lessen the risk.
ï¶Eg.-
cLMA
Flexible LMA
All LMs
Laryngeal tube
Cobra perilaryngeal
airway
Second Generation
ï¶Specially designed for
safety.
ï¶High pressure pharyngeal
seal.
ï¶Reduce the risk of
aspiration.
ï¶May be more efficacious
in ventilation.
Eg.-
PLMA,
Supreme LMA,
Laryngeal tube suction 2,
Laryngeal tube suction D,
i-gel,
SLIPA.
4. CLASSIFICATION
ⶠBased on sealing mechanism â
1.Cuffed perilaryngeal sealer:-
Non-directional non esophageal Sealers- cLMA, Flexible LMA, LMA
unique.
Directional Non-esophageal sealing- Fastrach LMA, ALMA.
Directional esophageal sealing- Proseal LMA, Suprem LMA.
2.Cuffed pharyngeal sealer:-
Without esophageal sealing:COPA, PAX.
With esophageal sealing:Combitube, L
T
,L
TS.
3.Cuff less preshaped sealer: -
With esophageal sealing- Baska mask, i-gel.
Without esophageal sealing- SLIPA , AirQ-SP
.
5. CLASSIFICATION
ⶠBASED ON THE NUMBER OF LUMEN-
1.Single Lumen Devices:-
LMA-classic, LMA-unique, LMA-flexible, ILMA, C-trach, Soft seal,
Laryngeal Airway Device(LAD), Ambu Laryngeal Mask,
Pharyngeal airway express(PAX), Cobra Perilaryngeal
Airway(CPLA), Laryngeal Tube(LT), Cuffed oropharyngeal airway,
Stream Lined Liner of the Pharyngeal Airway(SLIPA), Glottic
Aperture Seal Device.
2.Double Lumen Devices:- Proseal LMA, Combitube, Laryngeal
Tube Suction(L
TS), Airway Management Device(AMD).
3.Tripple Lumen Devices:- Elisha Airway Device(EAD).
6. INDICATION
ⶠAlternative airway during GA specially in short surgical
procedures and minor therapeutic or diagnostic procedures
like radiation therapy, diagnostic and interventional
radiology, endoscopy, ECTetc.
ⶠCardiopulmonary resuscitation to secure the airway.
ⶠEssential part of difficult airway trolley.
ⶠPrimary airway device when urgent airway patency is
required in lateral position as lessertime required to place
LMA in the lateral position as against endotracheal intubation
in this position.
ⶠRelative indication- in professional singers to avoid vocal cord
trauma.
7. CONTRAINDICATION
â¶
â¶
â¶
â¶
Limited mouth opening (<2 fingers)
Local pathology in pharynx , larynx or upperairway.
Trismus,facial or upper airway trauma
Increase risk of aspiration- Morbid obese, >14 week pregnant,
prior opiods medication, delayed gastric empting, acute
abdominal or thoracic injury, history of GERD, and hiatus hernia.
ⶠReduced lung compliance/increase work of breathing
8. ADVANTAGES
ï Increased speed and ease of
placement.
ï Less requirement of expertise.
ï Improved hemodynamic stability at
induction and during emergence of
anesthesia.
ï Minimal IOP and ICP changes during
insertion.
ï Increase airway tolerance.
ï Lowerfrequency of coughing during
emergence.
ï Improved oxygen saturation during
emergence
DISADVANTAGE
ïInadequate positive
pressure ventilation.
ïMore chances of aspiration
of gastric content.
ïSore throat.
ïVascularcompression and
nerve damage.
9. LMA- Classic
ï Comprised of three main components
â Airway T
ube
â Mask
â Inflation line
ï Maskdesigned to conform to the
contours of the hypopharynx with its
lumen facing the laryngeal opening.
ï Made of medical grade silicone, it
can be autoclaved and reused many
times.
ï Seal pressure =25cmH2O
10. SIZESELECTION
Mask Size Patient size /Body Weight Maximum Cuff
Inflation Volume (Air)
1 Neonates/Infants up to 5 kg Up to 4 mL
1.5 Infants 5â10 kg Up to 7 mL
2 Infants/Children 10â20 kg Up to 10 mL
2.5 Children 20â30 kg Up to 14 mL
3 Children 30â50 kg Up to 20 mL
4 Adults 50â70 kg Up to 30 mL
5 Adults 70â100 kg Up to 40 mL
6 Large Adults over 100 kg Up to 50 mL
11. PREPARATION PRIOR TO
INSERTION
ⶠSelect the propersize of LMA.
ⶠInspect the LMA for any tear , blockage .
ⶠSlowly deflate the cuff to form a smooth flat wedge shape .
ⶠOver inflate: look for leak.
ⶠUse a water soluble lubricant to lubricate the posterior surface of LMA
just prior to insertion.
ⶠAvoid excessive amounts of lubricant
-on the anterior surface of the cuff or
-in the bowl of the mask.
Avoid lignocaine jelly for lubrication .
12. INSERTION TECHNIQUE
ⶠPosition: Neck flexed and head extended.
ⶠUse non-inserting hand to stabilize occiput.
ⶠJaw should be pulled down by assistant.
ⶠLMA tube be grasped like a pen with index
finger pressing the point where tube joins
mask.
ⶠPlace the tip of the LMA against the inner surface
of the patientâs upper teeth.
ⶠAperture facing forward, the tip pressed
upwards against the hard palate.
ⶠMask is advanced into pharynx to ensure
that tip remains flattened and avoids the
tongue.
13. Continue..
ⶠNeck iskept flexed and head extended.
ⶠPress the mask into the posterior pharyngeal wall
using the index finger.
ⶠContinue pushing with your index finger and
guide the mask downward into position.
ⶠGrasp the tube firmly with the other hand and
then withdraw your index finger from the
pharynx.
ⶠPress gently downward with your other hand to
ensure the mask is fully inserted.
14. Continue..
ⶠInflate the mask with the
recommended volume of air
.
ⶠDo not over-inflate the LMA.
ⶠNormally the mask should be
allowed to rise up slightly out of the
hypo pharynx as it isinflated to find
itscorrect position.
ⶠInserta bite-block or roll of gauze to
prevent occlusion of the tube.
ⶠNow the LMA can be secured
utilizing the same techniques as
those employed in the securing of
an endotracheal tube.
15. OTHER METHODS OF
INSERTION
ⶠ1. Thumb index method.
ⶠ2.Partial inflation method.
ⶠ3.180 degree rotation method.
ⶠ4.Laryngoscopy aided method.
ⶠ5.Stylet aided method.
ⶠ6.Insertion from the side of the mouth opening.
16. SIGNS OF
CORRECT
PLACEMENT
ï The slight outward movement of the tube
upon LMA inflation.
ï The presence of a smooth oval swelling in
the neck around the thyroid and cricoid
area, or no cuff visible in oral cavity.
ï Ventilate the patient while confirming equal
breath sounds over both lungs in all fields
and the absence of ventilatory sounds over
the epigastrium.
Part of LMA Position
Distal tip of
silicone cuff
Upper esophageal
sphinter
Sides of the cuff Pyriform fossa
Upper part of the cuff Tounge base
17. PROBLEMS
ⶠFailure to press the deflated mask up against
the hard palate or inadequate lubrication or
deflation can cause the mask tip to fold back on
itself.
ⶠOnce the mask tip has started to fold over, this
may progress, pushing the epiglottis into its
down-folded position causing mechanical
obstruction .
ⶠIf the mask tip is deflated forward it can push
down the epiglottis causing obstruction
ⶠIf the mask is inadequately deflated it may
either
ⶠpush down the epiglottis
ⶠenter the glottis.
18. INTUBATION WITHC-LMA
ⶠ1.Blind intubation.
ⶠ2.Fibrescope guided.
ⶠ3.retrograde.
ⶠ4.Lighted stylet guided.
ⶠ5.Nasotracheal intubation.
DISADVANTAGES:-
1.Standard tube not long enough to insert.
2.Pilot tube may kincked.
3.Cricoid pressure make it difficult to pass the tube.
4.Paediatric-largest uncuffed tube too small to allow good seal for
PPV.
5.Removal of the LMA disturbs the ETtube
6. PPV not always possible due to moderate pharyngeal seal.
7.More riskof aspiration
19. Steps to reduce the chance
of aspiration
ï Routinely test the cuff for defects before
use.
ï Avoid lubricating the anterior surface of
the mask, since the lubricant may be
aspirated.
ï Insert the LMA only when adequate
depth of anesthesia has been reached.
ï Avoid disturbing the patient during
emergence from anesthesia.
ï Keep the cuff inflated till the patient is
awake.
Action after aspiration
ï Avoid in patients who are un-fasted, or
have factors predispose to regurgitation. 1. Do not attempt to remove
LMA.
2. Disconnect the circuit and
allow to drain the fluid while
head isdown & to the side.
3. Suction the LMA & give 100%
O2.
4. Ventilate manually with low
gas flow & small TV
.
5. Evaluate tracheobronchial
tree & suction the remaining
fluid with FOB.
6. Intubate when aspiration
below vocal cords.
20. LMA - UNIQUE
ⶠSingle use , PVC made ,
cheaper.
ⶠTube âstiffer , Cuff-less
compliant.
ⶠLess rise of intracuff presuure
with N2O.
ⶠMore difficult to insert.
ⶠSize same as cLMA.
21. FLEXIBLE LMA
ⶠFlexometallic tube- narrower & longer.
ⶠHas a rigid preformed angle at the cuff.
ⶠSeal pressure=20cmH2O
ⶠMore difficult to insert.
ⶠIntroducer helps to stabilize the airway tube
during insertion & it is removed once mask is
in place.
ⶠIt has a less incidence of dislodgement once
placed.
ⶠMore useful in head & neck surgeries, ENT and
upper torso procedures where need to
reposition the airway is prevalent
ⶠProblems-Disruption of spiral reinforce
wire, Increased airway resistance , limits
endoscope & tracheal tube passage ,
unsuitable forMRI.
22. AMBU AURA LARYNGEAL
MASK
ⶠAmbu Auraonce- single-use LM with a
preformed curve.
ⶠT
he Ambu Aura40 isthe reusable, silicone
version of the Ambu AuraOnce.
ⶠThe Ambu Aura-i designed to facilitate
intubation like ILMA.
ⶠThree parts- an airway tube, a mount area,
and a bowl including the inflatable cuff..
ⶠAll these three areas are molded as single
unit for extra safety -no separation..
ⶠFacilitate insertion without exerting force on
the upper jaw in neutral position.
ⶠA reinforced tip reduces the risk of the
device folding back during insertion.
ⶠintegrated inflation line and no epiglottic
barsat the airway orifice.
23. SOFT SEAL LARYNGEAL MASK
ⶠsimilar to the single-use LMA.
ⶠThe ventilation orifice iswider and it is
characterized by the absence of mask
aperture bars.
ⶠCuff ismore elliptical.
ⶠinsertion with the cuff partially inflated is
recommended.
ⶠA maximum intracuff pressure of 60 cm
H2O isrecommended.
ⶠmay be used as an intubation conduit.
ⶠThe large bowl of the device and itsPVC
Construction inhibit easy insertion.
24. PERILARYNGEAL AIRWAY
â« single use, PVC made, latex free .
â« Ithas a breathing tube with a large inner
diameter to increase air flow.
â« Inthe proximal end it has a standard 15 mm
connection
â« Novel head design- Grill of soft bar with Cobra
head shape.
ⶠLies infront of laryngeal inlet.
ⶠT
ip deflects epiglottis.
ⶠBars allow ventilation & instrumentation.
ⶠInternal ramp to guide ETTto wards glottis
Proximal high volume low pressure cuff- seals
hypopharynx.
PLA offers a more effective seal, and a better
fiberoptic score as the c-LMA.
25. ADVANTAGES
1. Easy to insert.
2. Large lumen allows larger ETT&
fibrescope.
3. Sealing pressure higherthan C-
LMA.
4. Can be used forparcutaneous
dilatational cricothyroidotomy.
DISADVANTAGES
1. Less airway protection â
as tip liesabove the
oesophageal inlet.
2. Airway obstruction.
26. INTUBATING
LARYNGEAL
AIRWAY
ⶠmedical-grade silicon and latexfree.
ⶠairway tube iscurved similar to the
anatomical curve of the upperairway
to eliminate the need to bend the tube
furtherduring use, which can lead to
kinking.
ⶠMask-keyhole outlet to direct ETTto
laryngeal inlet.
ⶠ3 ridges âon inflation of mask, these
ridges move against the posterior
pharynx and improve anteriormask
seal.
ⶠAfter intubation , ILA can be removed
without dislodging the ETTusing a
reusable "ILARemoval Styletâ.
ⶠLow airway seal, high risk of aspiration.
27. INTUBATING LMA
ⶠA modification of the c-LMA.
ⶠA rigid (stainless steel) anatomically
curved,short & wide bored shaft that
followsthe anatomical curve of the palate
and the post pharyngeal wall.
ⶠAn epiglottic elevator bar at the mask
aperture
ⶠArmoured flexible ETtube with a
longitudinal and a horizontal black line-
coincides with the epiglottic elevating bar.
ⶠT
he StabilizerRod of 25cm.
ⶠSeal pressure=60cmof H2O max.
Body
weight
ILMA size Air
volume
Tracheal
Tube
30-50kg 3 20ml 7mm
50-70kg 4 30ml 7.5mm
70-100kg 5 40ml 8mm
28. INSERTION
ⶠPosition: Neutral
ⶠHold rigid handle parallel to patientâs chest.
ⶠGlide the mask along the palate till the straight part of the rigid tube is
parallel to the chin.
ⶠRotate the rigid handle directing towards patientâs nose till it can not
be advanced.
ⶠInflate the cuff & check ventilation.
ⶠIntroduce FETTwith black line faceing rigid handle till 15 cm mark.
ⶠNow grip ILMA handle firmly and lift it forward by few mms without
levering.
ⶠAdvance the tube using clinical judgment.
ⶠInflate the cuff and check for tracheal intubation.
29. Continue..
ⶠAfter confirmation of tracheal intubation deflate the ILMA cuff.
ⶠRemove FETTconnector
ⶠInsert the stabilizing rod in the FETTto keep it in place.
ⶠRemove the ILMA gently over the stabilizing rod until it is clear of the
oral cavity.
ⶠStablize the FETTto prevent accidental extubation.
ⶠRemove ILMA and the stabilizing rod.
ⶠReconnect FETTconnector and the breathing circuit and
ⶠconfirm position again
30. CHANDYâS MANEUVER
ⶠThey increases the seal pressure and aligns the axes of trachea and
FETT
.
ⶠFirst step :Rotating ILMA in coronal & sagittal plane in an attempt to
find least resistant ventilation position.
ⶠSecond step :is to grasp the handle and use it to draw LMA forward
2-5 mm in a lifting action without levering teeth.
31. ADVANTAGES
â« Useful in âcanât intubate, canât
ventilateâ scenarios.
â« Allows fast insertion into correct
position without moving patientâs
head or neck.
â« Can be used alone or as a guide to
intubation.
â« Facilitates ventilation between ILMA
insertion and ETT insertion
â« Good conduit for fibreoptic
intubation in presence of blood or
clot in oral cavity.
â« Difficult laryngoscopic view is
irrelevent to the success of ILMA
intubation.
DISADVANTAGES
ïMore likely to dislodge in head or
neck manipulation.
ïUnsuitable forMRI.
ïDifficulty in insertion with limited
mouth opening.
ïOn removal of ILMA , tracheal tube
can be displaced downwards.
32. PROSEAL LMA
ⶠReusable , silicon made , most
specialized modification of c-LMA.
ⶠModifications:-
(i)oesophageal drain tube
(ii)posteriorinflatable cuff
(iii)reinforced airway tube
(iv) integral bite block
(v)introducer
Higherleak pressure(35cm of H2O)
than c-LMA(25cm of H2O).
Size-in 7 sizes(1-5) like the C-LMA with
drainage tube of
8,10,10,14,16,16&18 Fr respectively.
33. INSERTION
ⶠ(i) Standard: identical to the cLMA, but demanding
careful attention to detail.
ⶠ(ii) Introducer: a metal introducer is attached to
the concave side of the device. It is then
introduced in the same manner as an intubating
LMA.
ⶠ(iii) Bougie-guided: a bougie is placed upside down
into the oesophagus and the PLMA is railroaded
into place via the drain tube (suction catheters or
orogastric tubes are alternatives).This technique
had a significantly higher success rate.
ⶠPositioning:- The easy passage of an orogastric
tube into the stomach via the oesophageal
tube has been shown to correlate with optimal
anatomical airway positioning over the larynx.
34. ADVANTAGES
ⶠIncreased airway seal improves the PPV.
ⶠDecreased chance of aspiration-
1.Oesophageal opening isisolated from the airway.
2.Drain tube vents gas leaked into the oesophagus.
3.On regurgitation drain tube vents the fluid & small solid particles
beyond the pharynx.
4.The large bulk of the PLMA reduces the space available for
regurgitated fluid to âpoolâ.
5. Increased oesophageal and pharyngeal seal decreases the risk
of any pooled fluid entering the laryngeal inlet.
ⶠSimple tests enable correct positioning of the PLMA to be confirmed.
ⶠThe stomach may be accessed with an orogastric tube.
35. DISADVANTAGES
ⶠ1. Less suitable as an intubating device as an ILMA b/c narrow
airway tube.
ⶠ2.Slightly longer time required to insert than C-LMA.
ⶠ3.Can cause airway obstruction by- compression of supraglottic
structure or cuff in folding.
ⶠ4.Contraindicated for intraoral surgery .
36. LMA - SUPREME
ⶠSingle use, PVC made 2nd
generation LMA.
ⶠHas features of P-LMA, I-LMA & LMA
unique.
(i) Single use , PVC- (cf.LMA unique).
(ii)Large inflatable plastic cuff, but
no posteriorcuff (cf. PLMA)
(iii)Oesophageal drain tube
(iv)Preformed semi-rigid tube
(v)Fins in the mask bowl to prevent
epiglottic obstruction(cf. PLMA,
cLMA)
ⶠPharyngeal seal isintermediate
between cLMA and PLMA( 26â30
cm H2O)
ⶠOesophageal seal not reported.
37.
38. ADVANTAGES
The reinforced tip reduces the risk
of fold-over
, compared with the
PLMA.
Anatomic curve that facilitates
easy insertion.
A drain tube to allow gastric
which generates higher seal
pressure (36.1 vs 27.4cm H20 of
LMA unique).
ⶠA built-in bite block and fixation
tab to help secure the airway
ⶠ4- An oval airway crosssection
forimproved stability of the
airway
DISADVANTAGES
drain tube runs through the middle
of the airway tube (rather than
next to it in the PLMA) dividing it
into two narrow lumens.This limits
itsuse forairway inspection
aspiration. and foruse as a conduit for
ⶠA high volume/ low pressure cuff intubation.
Being made of PVC, the SLMA
may cause more trauma than
silicone devices
39. LMA C Trach
âą The LMA CTrach system is a new system for
airway management and endotracheal
intubation.
âą It is based on the ILMA (LMA Fastrach)
system with two in-built fiberoptic channels,
one to convey light from and the other to
convey the image to the viewer.
âą This fiberoptic system is sealed and robust,
and the Ctrach can be autoclaved.
âą The CTrach has an epiglottis elevating bar,
which elevates the epiglottis during passage
of the ETT through the Ctrach into the
larynx.
âą A rechargeable battery is provided for up to
30 minutes of continuous use. A charger
cradle for recharging the viewer is included
in the system
40. LMA C-Trach
ⶠEnables combined ventilation,
visualization, and intubation.
â« High first attempt intubation success rate
of 91%
.
â« Fiberoptic technology allows real time
visualization of the glottic opening and
of the ETtube passing through the vocal
cords.
â« Ideal in rescue/difficult airway situations
â« Completely portable and wirelesssystem
weighs less than eight ounces.
â« Easy to learn and very effective
41. INSERTION
ⶠInserted exactly the same as the LMA Fastrach.
ⶠOnce the airway is secured and patient is being ventilated
ⶠThe viewer is switched on, placed in the magnetic connector and a clear
image of the larynx is displayed in real time.
ⶠThe ET tube can be viewed as it enters the trachea. Once the patient is
intubated, the viewer is removed and the mask is removed leaving the ET
tube in place.
ⶠProblems:-
1. Ithas a poorer image quality than a flexible fiberoptic endoscope.
2.Itcannot be used easily in the patient with a limited mouth
opening.
3. The view may be obstructed by secretions, lubricant, or blood.
42. i-GEL
ⶠNovel SAD designed by UK anaesthetist,
Muhammed Nasir
.
ⶠ(i) Single use.
ⶠ(ii) Cuffless:the mask ismade of a soft
polymer and isshaped similarly to an
inflated LMA posteriorly with itsanterior
shape designed to âfit the perilaryngeal
structuresâ.
ⶠ(iii) Narrow-bore oesophageal drain
tube.
ⶠ(iv) Short, wide-bore airway tube.
ⶠ(v) Integral bite block
ⶠ(vi) Contains an epiglottic rest at the
anteriorpart of the cuff which reduces
the possibility of epiglottis âdown foldingâ
and airway obstruction.
43.
44. ContinueâŠ
ⶠMask ismade of a thermoplastic elastomer (SEBS-StyreneEthylene
Butadiene Styrene) that has the flexibility and feel of human tissue. .
After placement, body heat from the patient activates the gel component of
this airway which expands to fill the void in the hypopharynx where the
device rests.
Advantages:-
ⶠ1. easy to insert: due to a combination of a very,very low coefficient
of friction when lubricated & absence of cuff.
ⶠ2. truncated tip, with the aim of reducing post-use dysphagia.
ⶠ3. wide lumen make it well worth for both airway rescue and as a
conduit forassisted intubation.
ⶠ4. A gastric channel allows for suctioning and placement of a
nasogastric tube.
ⶠ5.Though oesophageal seal islow but enough (according to the
manufacturer).
45. LARYNGEAL TUBE
multiuse, latex-free, single-
lumen silicon tube
two low pressure cuffs
(proximal and distal).
ⶠThe distal balloon
(esophageal balloon) seals
the airway distally
ⶠThe proximal balloon
(oropharyngeal balloon)
sealsboth the oral and nasal
cavity.
ⶠTwo anterior,oval ventilating
ventsbetween the cuffs.
ⶠCough pressure 60cmH2O
ⶠ4 types-L
T
,L
T
-D, L
TS-II, L
T
s-D
46.
47. INSERTION
ⶠOpen the mouth app. 3 cm using
the thumb and index finger
technique in neutral position of
head.
ⶠHold like a pen in the area of the
teeth marks(three black marks).
ⶠInsert centrally along the hard
palate into the hypopharynx.
ⶠAdvance until a slight resistance is
felt. The center black line should n
be level with the upper front teeth.
ⶠInflate the cuffs considering the
respective colour code.
ⶠConnect bag to the 15 mm
standard connector.
ⶠplace the tube deeper, inflate the
cuffsand withdraw until ventilation
isoptimized results in the best depth
of insertion because tissue is
retracted away from the laryngeal
inlet.
49. ADVANTAGES
1. Easy insertion.
2. 2.High ventilation pressure can
be used.
3. Better protection from
aspiration.
4. Can be used to intubate the
trachea.
DISADVANTAGES
1.Airway obstruction.
2.Displacement on head &
neck movement.
3. Cuff rupture
4. T
rauma to pharynx.
50. ESOPAHGEAL- TRACHEAL
COMBITUBE
ⶠPVC double lumen supraglottic
airway device with two inflatable
balloons
ⶠ2 Lumens:tracheal and pharyngeal
ⶠVentilation -eithertracheal or
esophageal intubation
ⶠ95%of casestube enters the
esophagus
ⶠProximal balloon-seals the oral and
the nasal cavity
ⶠDistal balloon - sealseitherthe
esophagus or the trachea,
depending on which of these the
ETC has been sited.
ⶠSize-37 Fr for height up to 5 ft.
ⶠ41 Fr for height above 5.5 ft.
ⶠBetween 5-5.5ft â either of these.
51. INSERTION
ⶠNeutral position. Lift the tongue and
lower jaw upward to open the
oropharynx .
ⶠLubricate the tube with sterile, water
soluble lubricant.
ⶠInsert the Combitube so that it curves in
the same direction as the natural
curvature of the pharynx .
ⶠIf resistance ismet, withdraw tube and
attempt to reinsert.
ⶠAdvance tube until the patientâs teeth
are between the two black lines.
ⶠInflate the blue pilot cuff with 100ml of
airfrom the large syringe.
ⶠInflate the white pilot cuff with 15ml of
airfrom the small syringe.
ⶠBegin ventilation through the longer
tube . If auscultation of breath sounds is
good and gastric inflation isnegative,
continue and vice versa.
52.
53. INDICATION
1. Patientsin irreversible
respiratory arrest (i.e.
narcotic overdose,
hypoglycemia).
2. Patientsin cardiac arrest.
3. Ventilation in
normal/abnormal airways
4. Failed intubation
5. Unconscious patientswithout
a gag reflex, and in need of
ventilatory support
CONTRAINDICATION
1. Intact gag reflex
2. Under 4 feet tall & Under 16
years of age
3. Conscious âarouseable
patient
4. Known esophageal disease
(cancer, varices)
5. Ingestion of caustic
substances
6. Stoma or functional surgical
airway
7. Partial or complete FBAO
8. CONS
IDER:Latex Allergy
54. ADVANTAGES
1. Requires minimal training
2. May be more useful in non-
fasted patients
3. Successful passage and
ventilation in many patients via
esophageal route
4. Portable, useful in remote
setting
5. Functions in eitherthe trachea
or esophagus
DISADVANTAGES
1. Only adult and small adult
sizes
2. Potential foresophageal
trauma
3. Problems maintaining
seal in some patients
55. EASY TUBE
ⶠThe Easy Tube isnew disposable,
polyvinyl -chloride, double-lumen,
latex-free, supra-glottic airway
device.
ⶠIt has a close design to the
Combitube, intended to be more
friendly to use.
ⶠAllows ventilation in either
esophageal or tracheal position,
however it isexpected to enter the
esophagus in most cases.
ⶠHowever, the Easy Tube had a better
fiberoptic view and a shorter time to
achieve an effective airway, with
similar ventilatory performanceswith
the ETC
56. STREAMLINED LINEROF
THE PHARYNGEAL
AIRWAY
.
ⶠPlastic made, uncuffed, disposable ,2nd
generation SAD.
ⶠAnatomically pre-shaped to line the
pharynx.
ⶠHollow & boot shaped distal part-
1
. T
oe- rest in the oesophageal entrance
2. Bridge- fits to the pyriform fossa.
3. Heel- anchor in correct position &
connect the airway tube.
4
. T
wo lateral bulges- relieve pressure on
Hypoglossal& recurrent laryngeal NV.
5. Large capacity chamber-store
regurgited fluid.
Available in 6 sizes- relate to dimension
across the bridge: 47, 49, 51, 53, 55, and
57 mm.
57. ADVANTAGES
1. Easy to insert.
2. Greater airway sealing pressure.
3. N2O has no effect on sealing
pressure-as no cuff.
4. Effective protection against
aspiration during PPV
CONTRAINDICATED
Upperairway
abnormality.
58. CUFFED OROPHARYNGEAL
AIRWAY
â« PVC made , single use ,1st generation.
ⶠThe distal cuff inflate below the soft
palate, behind the tongue,above the
epiglottis, and within the oropharynx.
ⶠAvailable in five sizes: 7, 8, 9, 10, and 11
cm length with cuff inflation volume of 20,
25, 30, 35, and 40 ml respectively.
ⶠInsertion like Gudelâs oropharyngeal
airway.
ⶠCOPA isrecommended foruse in
spontaneously breathing patients with no
risk factorsforaspiration.
â« It isquick and easy to place.
â« Easy size selection & low cost.
â« Less airway protection
59. ELISHA AIRWAY DEVICE
ⶠSilicon made , latex free, latest.
ⶠthree separate channelsforventilation,
intubation, and gastric tube insertion.
ⶠVentilation channel (VC) and
Intubation channel (IC) are side-by-side
but join at the ventilation outlet situated
in front of the laryngeal inlet.
ⶠThe VC has a standard 15 mm
connector at th proximal end.
ⶠThe IC allows passage of an 8.0 mm ET
tube forblind orfiberoptic-guided
intubation.
ⶠGastric tube channel (GTC) has an
outlet located in the distal end of the
device.
60. ⶠTwo high-volume, low-pressure cuffs.
ⶠProximal cuff seals the oropharynx and nasopharynx & distal
cuff sealsesophagus.
ⶠBoth are inflated through a single pilot port with 50 cc of air
resulting in an intra-balloon pressure of approximately 70 cm
H2O.
ⶠProvide combination of 3 functions in a single device:
ventilation, intubation (blind and/or fiberoptic-aided) without
interruption of ventilation, and gastric tube insertion.
61. OTHER NEWER SAD
ⶠEldorLaryngeal Airway.
ⶠGlottic Aperture Seal Airway.
ⶠGlossopalatine Tube. Etc.
62. EFFICACY VS SAFETY
ⶠFor the evaluation of efficacy (absolute & relative ) small clinical
trialscan be used.
ⶠContrary, evaluations of safety (like ventilation failure rates , more
pertinently the risk of aspiration ) may need studies in larger scale
with larger populations.
ⶠTherefore the risk profile of a new device (unless it is particularly
unsafe) isunlikely to be established for several years after
introduction.
63. SUMMARY
ⶠThere is no solid evidence of any device performing better than
the classic LMA among the first generation SADs.
ⶠIn the second-generation SADs-The PLMA proved top be very
efficacious and safe in both routine and advanced uses
ⶠSAD with a drain tube has become the first choice as the
standard of care.
ⶠOthernewerSADs like i-gel, SLMA, and L
TS-IIhave increasing
positive evidence of their superiority.
ⶠAll these developments in the field of SAD paved the way to take
an ever larger role in modern airway management.