SUPRAGLOTTIC..BUSKA...IGEL

1. SUPRAGLOTTIC AIRWAY
DEVICES
DR ZIKRULLAH

2. OVERVIEW
• INTRODUCTION
• HISTORY
• CLASSIFICATION
• INDICATION/CONTRAINDICATION
• COMPLICATION
• TECHNIQUE OF INSERTION
• INDIVIDUAL DESCRIPTION
• SUMMARY

3. INTRODUCTION
• Devices that are used to maintain the airway
patency and provide ventilation by placing
just above the glottic opening.
• They sit outside the trachea and provide a
hands free means of gas tight airway.
• Standard of airway management , filling the
niche between facemask and tracheal tubes.

4. .
• SUPRAGLOTTIC DEVICES
Airway devices that ventilate patients by delivering
anaesthetic gases/oxygen above the level of the
vocal cords, regardless of the location of the device
in relation to the glottis.
• EXTRAGLOTTIC DEVICES
Any airway device with its distal end located
outside the glottis
DIFFERENCE BETWEEN

5. HISTORY
•Dr. Archie Brain developed LMA in 1981 as a
modification of Goldman dental mask with ET tube.
•The first commercially available supraglottic airway
device was LMA-Classic(1988).

6. CLASSIFICATION
• A)Based on Generation:-
First Generation
Simple airway device.
 Low pressure pharyngeal seal
May or may not protect from aspiration.
Have no specific design to lessen the risk.
Eg.-
cLMA
Flexible LMA
Laryngeal tube
Cobra PLA

7. .• Second Generation
Specially designed for safety.
High pressure pharyngeal seal.
Reduce the risk of aspiration.
May be more efficacious in ventilation.
• Eg.-
• PLMA
• Supreme LMA,
• LTS,
• I-gel, SLIPA
• Air Q

8. Third generation :
• Cuffless, two drain tubes, small bowl
• Eg -
BASKA Mask

9. CLASSIFICATION
• B)Based on sealing mechanism –
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.

10. 2.Cuffed pharyngeal sealer:-
Without esophageal sealing: COPA, PAX.
With esophageal sealing: Combitube, LT, LTS.
3.Cuff less preshaped sealer: -
With esophageal sealing- Baska mask, i-gel.
Without esophageal sealing- SLIPA , AirQ-SP.

11. CLASSIFICATION
C)Based 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.

12. 2.Double Lumen Devices:-
Proseal LMA, Combitube, Laryngeal Tube
Suction(LTS), Airway Management
Device(AMD)
3.Tripple Lumen Devices:-
Elisha Airway Device(EAD)

13. INDICATIONS ?
1-) Supraglottic devices have been recommended as
rescue airways in CVCI scenario.
2-) Procedures outside the operating room-
-Radiology and MRI
- Radiation Therapy
- Diagnostic and short therapeutic procedures
in children

14. 4-) Pulmonary medicine and Thoracic surgeries
- Bronchoscopy
- Laser surgery of the trachea
- Tracheobronchial stent placement
5-) Neurosurgery

15. CONTRAINDICATIONS ?
• ABSOLUTE
-Cannot open mouth
-Complete airway obstruction
• RELATIVE
-Increase risk of aspiration
-Prolonged bag and mask ventilation
-Morbid obesity
-Second and third trimester pregnancy
-Upper GI bleed
-Abnormality in supraglottic airway
-Need for high airway pressure
-Patients who have not fasted

16. ADVANTAGES OF LMA OVER ETT ?
• Increased speed and ease of placement
• Improved hemodynamic stability at induction and during
emergence
• Reduced anesthetic requirements for airway tolerance
• Lower frequency of coughing during emergence
• Improved oxygen saturation during emergence
• Lower incidence of sore throats in adults

17. ADVANTAGES OF LMA OVER
FACEMASK
• Easier placement by inexperienced
personnel
• Improved oxygen saturation
• Less hand fatigue
• Improved operating conditions during
minor surgery

18. .
Disadvantages of LMA over the
ETT ?
• Lower seal pressure
• Higher frequency of gastric insufflation
Disadvantages of LMA over the
FM ?
• Esophageal reflux more likely

19. COMPLICATIONS
• Lubricant applied on LMA promote cough &
laryngospasm.
• Folding of epiglottis tip between vocal cords causes
coughing,laryngospasm,labored breathing & airway
obsruction.
• Aspiration & regurgitation of gastric contents.

20. • Sore throat
• Failed LMA placement
• Odema of epiglottis, uvula, post pharyngeal wall
• Hypoglossal nerve paralysis, post op pulmonary
edema, tongue cyanosis, transient dysarthria,
tension pneumoperitoneum, gasric rupture.

21. LARYNGEAL MASK AIRWAY
FAMILY
• Classic LMA
• LMA Unique
• LMA Flexible
• LMA Fastrach
• LMA C Trach
• LMAAirQ
• LMA ProSeal
• LMA Supreme
IT COMPRISES OF ?

22. CLASSIC LMA
• Latex free, medical-grade silicone - throat irritation
• Consists of a curved tube connected to an elliptical spoon-
shaped mask at 30° angle

23. .
• Cuff Pressure- 60 cm H2O
• Reusable 40 times
• May be inserted blindly without muscle relaxants
• Two flexible vertical Aperture bars where the
tube enters the mask- prevent the tube being
obstructed by the epiglottis.
• Airway tube is slightly curved, semi rigid, semi-
transparent.

24. Maximum
Cuff Inflation
Volume (Air)
1 Neonates/Infants up to 5 kg up to 4 ml
1½ Infants 5-10 kg up to 7ml
2 Infants/children 10-20 kg up to 10 ml
2½ Children 20-30 kg up to 14 ml
3 Children 30-50 kg up to 20 ml
4 Adults 50-70 kg up to 30 ml
5 Adults 70-100 kg up to 40 ml
6 Large adults over 100kg up to 50 ml
Patient Selection
Guidelines
Mask
Size
LMA SIZE SELECTION ?

25. PREPARATION PRIOR TO
INSERTION
• Select the proper size of LMA.
• Inspect the LMA for any tear , blockage .
• Slowly deflate the cuff to form a smooth flat wedge shape .
• Over inflate: look for leak.
• Use a water soluble lubricant to lubricate the posterior
surface of LMA just prior to insertion.
• Avoid excessive amounts of lubricant
-on the anterior surface of the cuff or
-in the bowl of the mask.

26. INSERTION TECHNIQUE
• Position: Neck flexed and head extended.
• Use non-inserting hand to stabilize
occiput.
• Jaw should be pulled down by assistant.
• LMA tube be grasped like a pen with
index finger pressing the point where tube
joins mask.
• Place the tip of the LMA against the inner
surface of the patient’s upper teeth.

27. •Aperture facing forward, the tip pressed
upwards against the hard palate.
•Mask is advanced into pharynx to ensure
that tip remains flattened & avoids
tongue.
• Neck is kept flexed and head extended.
• Press the mask into the posterio -
pharyngeal wall using the index finger.
•Continue pushing with your index finger
and guide the mask downward into position.

28. Continue..
• Grasp the tube firmly with the other hand
and then withdraw your index finger from
the pharynx.
• Press gently downward with your other
hand to ensure the mask is fully inserted.
•
•
• Inflate the mask with the recommended
volume of air.
• Do not over-inflate the LMA.

29. Continue..
• Normally the mask should be
allowed to rise up slightly out of
the hypo pharynx as it is inflated
to find its correct position.
• Insert a bite-block to prevent
occlusion of the tube.
• Now the LMA can be secured.

30. OTHER METHODS OF
INSERTION
1. Thumb index method.
2.Partial inflation method.
3.180 degree rotation method.
4.Laryngoscopy aided method.
5.Stylet aided method.
6.Insertion from the side of the mouth
opening.

31. SIGNS OF CORRECT PLACEMENT
Slight outward movement of tube upon LMA inflation.
 Presence of a smooth oval swelling in the neck around thyroid
& cricoid area, or no cuff visible in oral cavity.
Ventilate the patient while confirming equal breath sounds over
both lungs in all fields & absence of ventilatory sounds over
epigastrium.
Part of LMA Position
Distal tip of silicone cuff Upper esophageal
sphinter
Sides of the cuff Pyriform fossa
Upper part of the cuff Tongue base

32. PROBLEMS
• Failure to press the deflated mask up
against the hard palate or inadequate
lubrication or deflation can cause mask
tip to fold back on itself.
• Once mask tip has started to fold over,
this may progress, pushing the epiglottis
into its down-folded position causing
mechanical obstruction .

33. •If the mask tip is deflated
forward it can push down the
epiglottis causing obstruction
•If the mask is inadequately
deflated it may either
•push down the epiglottis
•enter the glottis.

34. LMA UNIQUE
• Made of PVC
• Tube is stiffer and the cuff less compliant
• Helpful to warm it prior to insertion
• Intracuff pressure increases significantly less in the
LMA Unique when nitrous oxide is used
•.
•No risk of cross
infection
•Convenient, single-
use, disposable
•Sizes available from
1 to 6

35. FLEXIBLE LMA
• It has a long flexible, wire reinforced tube , cuff sizes are the same
• A single use version is also available
• Surgery on the head, neck & upper torso
• Increase airway resistance
•.

36. SOFT SEAL LMA
• Similar to LMA Unique
• Cuff is softer, blunter &
less permeable to N2O
• Integrated inflation line
• No epiglottic bars
• Wider ventilation orifice
• Sizes 1-5

37. LMA Fastrach
U
• Designed to facilitate tracheal intubation, can also be used as
a primary airway device. It is especially useful for anticipated
or unexpected difficult airway
• It can be used with the patient in the lateral position.
• Enables ventilation during intubation attempts

38. .• A difficult laryngoscopy view is irrelevant to successful
ILMA intubation
• No cervical spine movement is required
• Placement does not require the operator to be above the
patients head

39. •.
Air-Q

40. Air-Q
• Use both as a stand-alone laryngeal mask airway and
as a rescue device
• Air-Q™ Disposable allows for intubation using
standard oral ETTS, sizes 5.5 to 8.5.
• Clinicians can easily remove the air-Q™ Disposable
with the removal stylet without dislodging the ET
tube.
• Removal Stylet is reusable up to 10 times. stylet is not
autoclavable.
• Available in six sizes – 1, 1.5, 2, 2.5, 3.5, 4.5 •.

41. LMA CTrach™
•Increase intubation success rates in difficult airway.
•Built in fibreoptics provide a direct view of larynx.
•Real time visualisation of ET passage through vocal cords.
•Sizes 3,4,5 & is reusable upto 20 times.
•Poorer image quality than a flexible fiberoptic endoscope.

42. ProSeal LMA
• LMA-ProSeal is shorter & smaller in diameter than c-LMA
• Dorsal cuff pushes the mask anteriorly to provide a better
seal around the glottic aperture & helps to anchor device in
place
• Sizes-1.5 ,2, 2.5 ,3, 4, 5

43. Advantages over classic LMA
• Increase airway seal improves PPV.
• Gastric tube port- for gastric access, checking correct
positioning, bougie guided insertion.
• Dorsal cuff- better seal and airway pressure- not
present in 2 ½ & below.
• Bite block
• Strap/Hinge for hooking the bougie/introducer.
• Decrease chances of aspiration-isolated esophageal
opening, on regurgitation drain tube vents fluid &
small solid particles beyond pharynx
,

44. DISADVANTAGES OF PLMA?
• Less suitable as an intubating device as an ILMA
because narrow airway tube.
• Slightly longer time required to insert than C-LMA.
• Can cause airway obstruction by- compression of
supraglottic structure or cuff in folding.
• Contraindicated for intraoral surgery .
• 20% more airway resistance than classic airway.

45. LMA Supreme
• Disposable
• Double lumen tubes
• The airway tube has a
gentle curve & oblong
shape
• Easy insertion and
stable placement
molded fins in the bowl
of the mask to prevent
epiglottic down folding

46. AMBU AURA LARYNGEAL MASK
• Latex free, extra soft cuff
• Ambu Auraonce- single-use LM with a
preformed curve.
• The Ambu Aura40 is the reusable,
silicone version of the Ambu AuraOnce.
• The Ambu Aura-i designed to facilitate
intubation like ILMA.
• Three parts- an airway tube, a mount
area, and a bowl including the
inflatable cuff..

47. •All these three areas are molded as
single unit for extra safety - no
separation..
•Facilitate insertion without exerting
force on the upper jaw in neutral
position.
•A reinforced tip reduces the risk of the
device folding back during insertion.
•integrated inflation line and no
epiglottic bars at the airway orifice.

48. LARYNGEAL TUBE
• Multiuse, latex-free, single-
lumen silicon tube
• Two low pressure cuffs
(proximal and distal).
• The distal balloon
(esophageal ) seals the
airway distally
• The proximal balloon
(oropharyngeal ) seals both
oral & nasal cavity.

49. • Two anterior ,oval ventilating vents between
the cuffs.
• Cough pressure 60cmH2O
• 4 types- LT, LT-D, LTS-II, LTs-D

50. •.

51. ESOPAHGEAL- TRACHEAL
COMBITUBE
• Latex made, double lumen with two
inflatable balloons
• 2 Lumens: tracheal and pharyngeal
• Ventilation -either tracheal or
esophageal intubation
• 95% of cases tube enters the esophagus
• Proximal balloon-seals the oral and the
nasal cavity
• Distal balloon - seals either the
esophagus or the trachea, depending on
which of these the ETC has been sited.

52. Esophageal Placement (90-97%)
• If the Combitube is placed in
the esophagus, the distal
balloon will occlude the
esophagus.
• Ventilations are then provided
through perforations in the
side of the pharyngeal tube.
Stomach contents can then be
safely expelled via the hole in
the end of the tube.

53. Tracheal Placement (3-10%)
• If placed in the trachea, it
functions as an endotracheal
tube, with the distal balloon
preventing aspiration.
• Ventilations are then provided
via the hole in the end of the tube
as in an endotracheal tube.
• Stomach contents can then be
safely expelled via perforations in
the side of the pharyngeal tube.

54. COMBITUBE
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 either the
trachea or esophagus
DISADVANTAGES
1. Only adult and small
adult sizes
2. Potential for esophageal
trauma
3. Problems maintaining
seal in some patients

55. EASY TUBE
• Disposable, polyvinyl -chloride,
double-lumen, latex-free
• It has a close design to the
Combitube, intended to be more
friendly to use.
• Allows ventilation in either
esophageal or tracheal position,
however it is expected to enter the
esophagus in most cases.
• Had a better fiberoptic view &
shorter time to achieve an effective
airway, with similar ventilatory
performances with the ETC

56. SLIPA
•Looks like a slipper
•Soft, hollow, blow-molded
plastic airway that is shaped
like a boot
•Toe sits in the hypopharynx
•Bridge with its two lateral
bulges, fits into the pyriform
fossae
•Heel of the chamber anchors
the SLIPATM

57. CUFFED OROPHARYNGEAL
AIRWAY
 PVC made , single use ,1st generation.
• The distal cuff inflate below the soft
palate, behind the tongue, above the
epiglottis, and within the oropharynx.
• Available in five sizes: 7, 8, 9, 10, and
11 cm length with cuff inflation volume
of 20, 25, 30, 35, and 40 ml respectively.

58. Cobra Pharyngeal Lumen Airway
• Alternative to a facemask
• Alternative and useful device in
a “ difficult to intubate/difficult
to ventilate” scenario
• Does not provide protection
against regurgitation and
aspiration
• Sizes 8 (0.5- 6)

59. .
I-Gel
• Single-use non-inflatable mask made of a gel-like
thermoplastic elastomer.
• Epiglottic rest to prevent epiglottic downfolding

60. I-GEL
• Anatomical seal of
pharyngeal, laryngeal &
perilaryngeal
structures
• Separates resp & GI tracts
• Buccal cavity stabliser
• Built- in bite block
• Minimal tissue compression
•.

61. COMPLICATIONS of I-GEL
• An increased risk of airway problems
• Gastric insufflation
• Regurgitation & pulmonary aspiration
• Stimulation of pharyngolaryngeal reflexes
• Trauma to pharyngeal structures
• Compression of neurovascular elements
• Fragmentation or herniation of the LMA

62. •Insertion like Gudel’s oropharyngeal airway.
•COPA is recommended for use in spontaneously
breathing patients with no risk factors for
aspiration.
• It is quick and easy to place.
• Easy size selection & low cost.
• Less airway protection

63. ELISHA AIRWAY DEVICE
• Made up of Silicone
• 3 separate channels for ventilation,
intubation, and gastric tube insertion.
• VC& IC are side-by-side but join at
the ventilation outlet situated in front
of the laryngeal inlet.
• IC allows passage of an 8.0mm ETT
for blind or fiberoptic-guided
intubation.
• GTC has an outlet located in the
distal end of the device.

64. .
• Two high-volume, low-
pressure cuffs.
• Proximal cuff seals
the oropharynx and
nasopharynx & distal
cuff seals esophagus.
• Both are inflated
through a single pilot
port with 50 cc of air
resulting in an intra-
balloon pressure of
approximately 70 cm
H2O.

65. IDENTIFY ?

66. BASKA MASK

67. • BASKA Mask is a cuffless device with a
membranous bowl which inflates with each positive
pressure and then deflate to atmospheric levels
during passive expiration.
• Smaller bowl compared to other LMAs – less risk of
including esophageal opening.
• Tab for manually curving the mask for easy
insertion.
• Double gastric channel- one channel is open to air
so .less gastric opening chance of oesophageal wall
impinging the .. during suction

68. CLEANING AND STERILIZATION
• Dilute solution of( 8-10%w/v) sodium bicarbonate,
soapy water may be used
• Formaldehyde, glutarldehyde , ethylene oxide not
to be used
• Prolonged immersion in chlorhexidine to be
avoided
• Cuff should be deflated immediately prior to
autoclaving as spontaneous reinflation occurs over
a few hours

69. .• No residual air/fluid should be left in the cuff
• It was seen that if residual air was 0.25ml elasticity
of the cuff decreased considerably. If it was 1 ml
10% of the cuffs ruptured.
Minimum exposure time for steam sterilization at
132-135◦C
Autoclave wrapped unwrapped
Gravity 10-15 mins 10 mins
Prevaccum 3-4 mins 4 mins

70. CONCLUSION
• No single device meets all the criteria for the ideal SAD.
• Second-generation SADs are likely to provide better
airway protection, and their use is increasing in clinical
practice.
• Airway providers should be skilled with several devices
and techniques, including various SAD devices, to be
considered competent in airway management.