Supraglottic airway devices

1. SUPRAGLOTTIC
AIRWAY DEVICES
DR ZIKRULLAH

2.  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

3. HISTORY
 Prior to 1874,little was known about the anatomic
causes of upper airway obstruction that frequently
terrified the early practitioners of inhalation
anaesthesia
 Howard in 1880,showed that pulling the tongue
forward produced a clear airway by elevating its
base from the posterior pharyngeal wall . this
contrasted the then held view that tongue traction
relieved airway obstruction by lifting the epiglottis.

4.  In 1870s Joseph Thomas Clover of Britain
maintained a patent airway by using a
nasopharyngeal tube
 In 1908,Frederick Hewitt published a paper in
Lancet describing the forerunner to many modern
oropharyngeal airway devices
 Over the next 15-20 years ,Clover’s
nasopharyngeal airway and Hewitt’s oropharyngeal
airway were extensively adapted to allow
administration of volatile anaesthesia

5.  In 1934,WB Primrose, described a cuffed
oropharyngeal throat tube
 In early 1940’s the fall of extraglottic airway
management was primarily due to rapid advances
in the quality and availabilty of endotracheal tube
equipment
 The concept of difficult airway arose during this
time as a result of the high failure rate of
laryngoscope guided tracheal intubation
 The main non surgical approach to the difficult
airway at that time was blind nasal intubation ,
pioneered by Magill and Rowbotham 20 years
earlier.

6.  In 1981, Dr Archie Ian Jeremy Brain ,a 39 year old
anaesthetist working in London developed the LMA.
The cuff of the goldman dental mask was used to
make the first laryngeal prototypes.
 He was born in Japan on july 2,1942. the LMA was
his 13th patent application and was granted in 1982.

8.  1983 : first use for airway rescue
 1987 : first use for resuscitation
 1993 : included in ASA algorithm for difficult
airway
 2002 : 150 million uses worldwide

9. 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

10. ADVANTAGES OF LMA OVER
FACEMASK
 easier placement by inexperienced personnel
 improved oxygen saturation
 less hand fatigue
 improved operating conditions during minor surgery

11. Disadvantages of LMA over the ETT
 lower seal pressure
 higher frequency of gastric insufflation
Disadvantages of LMA over the FM
 esophageal reflux more likely

12. CLASSIFICATION
ON THE BASIS OF LUMEN
 Single Lumen Devices: LMA-classic, LMA-unique,
LMA-flexi, ILMA, C-Trach, Soft Seal, Laryngeal
Airway Device, Pharyngeal Airway Xpress, Cobra
Peri Laryngeal Airway, Laryngeal Tube, Cuffed
Oropharyngeal Airway, Stream Lined Liner of the
Pharyngeal Airway, Glottic Aperture Seal Device.
 Double Lumen Devices: Proseal LMA ,
Combitube, Laryngeal Tube Suction, Airway
Management Device.
 Triple Lumen Device: Elisha Airway Device.

13. ON THE BASIS OF SEALING MECHANISM :
 CUFFED PERILARYNGEAL SEALERS :
a . Non directional sealers – LMA , ILMA ,
LAD, Soft seal
b . Directional sealers – PLMA
 CUFFED PHARYNGEAL SEALERS :
a . Without esophageal sealing – COPA , PAX
b . With esophageal sealers – Combitube , LT,
LTS
 CUFFLESS PRESHAPED SEALERS :
SLIPA, I gel

14. LARYNGEAL MASK AIRWAY
FAMILY
 Classic LMA
 LMA Unique
 LMA Flexible
 LMA Fastrach
 LMA C Trach
 LMA AirQ
 LMA ProSeal
 LMA Supreme

15. CLASSIC LMA
 Latex free, medical-grade silicone - throat irritation
 Consists of a curved tube connected to an elliptical
spoon-shaped mask at 30° angle to facilitate
tracheal intubation
 The airway tube is slightly curved, semi rigid, semi
transparent

16.  Two flexible vertical Aperture bars where the tube
enters the mask to prevent the tube being
obstructed by the epiglottis.
 Cuff Pressure- 60 cm H2O
 Reusable 40 times
 May be inserted blindly without muscle
relaxants

17. LMA CLASSIC

18. LMA SIZE SELECTION
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

19. MODIFICATIONS
 Short tube LMA
 Split LMA
 Double lumen LMA
 Large bore LMA
 Barless LMA
 AMBU LMA
 MRI compatibility ( Halkey roberts pilot balloon
valve with non magnetic silicone spring)

20. AMBU LMA
 Latex free, extra soft cuff
 Special curve that replicates human anatomy
 Reinforced tip does not bend during insertion

21. 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

22. LMA UNIQUE
•No risk of cross
infection
•Convenient, single-
use, disposable
•Sizes available from
1 to 6

23. FLEXIBLE LMA
 It has a long flexible, wire
reinforced tube
 The cuff sizes are the same
 A single use version is also
available
 Surgery on the head, neck &
upper torso

24.  Increased airway resistance

25. 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

26. LMA FASTRACH
U
 Although the LMA-Fastrach has been designed to facilitate
tracheal intubation, it can also be used as a primary airway
device. It is especially useful for the anticipated or
unexpected difficult airway
 It can be used with the patient in the lateral position.
 Enables ventilation during intubation attempts

27.  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

32. AIR-Q
 Specifically engineered for use both as a stand-alone
laryngeal mask airway (LMA) and as a rescue device
 The air-Q™ Disposable allows for intubation using
standard oral endotracheal tubes, sizes 5.5 to 8.5.
 Clinicians can easily remove the air-Q™ Disposable with
the Removal Stylet without dislodging the ET tube.
 The Removal Stylet is reusable up to 10 times. The stylet
is not autoclavable.

33.  Available in 4 colour-coded sizes: 1.0, 1.5, 2.0, 2.5,
3.5, 4.5.
 Single patient use
 Sizing Chart
 Max. TT Size
 4.5Adults 70 - 100 kg 8.5
 3.5Adults 50 - 70 kg 7.5
 2.5Children/Adults 20 - 50 kg 6.5
 1.5Pediatric 5.5

35. LMA CTRACH™
• intubation success rates in difficult airways
• Built-in fiberoptics provide a direct view of the larynx
• Real time visualization of the ETpassing through the vocal cords
• Sizes 3, 4, and 5 and is reusable up to20 times
• Poorer image quality than a flexible fiberoptic endoscope

37. PROSEAL LMA
The airway tube of the LMA-ProSeal is shorter and smaller
in diameter than that of the LMA-Classic
Dorsal cuff pushes the mask anteriorly to provide a better
seal around the glottic aperture and helps to anchor the
device in place
The dorsal cuff is not present on sizes 11/2 to 21/2

38. LMA PROSEAL
Introducer Cuff Deflator
1½, 2, 2½, 3, 4, 5

40. ADDITIONAL FEATURES
 Improve the laryngeal seal without increasing
mucosal pressures
 Separate the respiratory and alimentary tracts
 Higher airway seal pressures for PPV
 Built-in bite block
 Drain tube
 Introducer for Insertion

42. LMA SUPREME
 Disposable
 Double lumen tubes
 Hybrid of PLMA and ILMA
 The airway tube has a gentle
curve and oblong shape
 Easy insertion and stable placement molded fins in
the bowl of the mask to prevent epiglottic down folding

44. PREDICTORS OF DIFFICULT
PLACEMENT
 Disrupted upper airway(trauma,ingestion of
caustics)
 Restricted mouth opening(<2 cm)
 Obstruction of the upper airway (mass, foreign
body,edema)
 Poor lung or thoracic compliance

45. PLACEMENT OF LMA
 Preoxygenation
 Coinduction
 Assessment of depth
 Insertion,cuff inflation and fixation
 Assessment of function and anatomic position

46. PREOXYGENATION
 All patients undergoing iv induction must be
preoxygenated.
 Technique is unimportant provided there is a good
seal.
 Normal tidal volume for 3 minutes
 3 vital capacity breaths
 End tidal O2 90-95%

47. COINDUCTION AGENTS
 Facilitate LMA insertion
 Topical lignocaine is more effective than iv
lignocaine
- unpleasant
- during application protective reflexes can be
activated
-once protective reflexes are obtunded the risk of
aspiration may be increased
 Use of even minidose of muscle relaxants improves
insertion

48. INDUCTION
 Unpremedicated adults require atleast 2mg/kg of
propofol and children atleast 4mg/kg.
 MACLMA insertion for sevoflurane for 50% and 95%
of patients is about 1.5-2% and 2-2.5%respectively
 It is reduced in additive fashion by N2O
 MACLMA insertion for halothane is 1.4-1.7%
 Ketamine given in dose of 3-3.5mg/kg

49. IV OR INHALATIONAL INDUCTION
 Thiopentone similar to propofol when combined
with coinduction agent
 Propofol and sevoflurane provide similar insertion
condition . But hypotension more common with
propofol.

50. ASSESSMENT OF DEPTH
 Lack of response to jaw thrust is a reliable clinical
indicator
 Loss of verbal contact and eyelash unreliable
 Insertion should be timed to coincide with maximum
anaesthesia effect. This occurs 2 minutes after
completion of injection using propofol
 During this time nonirritant inhalational agent with
low blood /gas solubility should be administered via
facemask

51. INSERTION TECHNIQUE
 Standard technique:
-midline
-lateral
-thumb

52.  Choose the appropriate size and check the cuff for
leaks
 Cuff deflated,lubricate the posterior surface
 With rim facing posteriorly.hold with dominant hand
like pen
 Sniffing position. Nondominant hand behind occiput
 Inspect mouth. Flatten against palate

53.  Index finger pressed towards occiput.finger and
wrist flexed
 Jaw should not be held open once the mask is in
the mouth
 Follow palatopharyngeal curve. lateral approach if
resistance
 Finger straightens and wrist internally rotates as
LMA advances
 Finish insertion when resistance encountered

57. ALTERNATIVE TECHNIQUES
 Change in cuff volume
 Laryngoscope guided
 Reverse /guedel technique
 Alternative finger position
 Manipulation of jaw, mouth ,head and neck
-jaw thrust (reduces the frequency of epiglottis
downfolding but does not increase insertion
success)
-extra mouth opening
-external manipulation of neck
(TRIPLE AIRWAY MANEUVRE )

58.  Artificial palates
-Spoons
-modified oral airways(dingleys artificial palate)
 Intra and extra tube insertion tools
-intratube: stylet, bougie,Trachlite
-extratube: blades, forceps
 Drain and airway tube
 Active swallowing

59. CUFF INFLATION
 Should be inflated to 2/3rd of maximum
recommended volume and then adjust to just seal
volume
 Should not be less than 1/4th of the maximum
recommended volume(at this seal with GIT fails)

60. OVERINFLATION
 Efficacy of seal with repiratory tract:
-most effective @1/3rd -2/3rd of the maximum
recommended volume
-after this little further increase with increase in
volume
-overinflation may eject the cuff from pharynx
 Seal with GIT:
-most effective seal with GIT is at higher volume than
respiratory tract but follows a similar pattern

61.  increased pharyngolaryngeal morbidity
 May interfere with surgical field
 Anatomic distortion
- carotid compression
- IJV displaced
-displacement of pathology
-surgical misdiagnosis
 Esophageal sphincter tone
-LES tone unaffected,UES tone may be decreased
 Emergence charachteristics are generally
unaffected by cuff volume

62. UNDERINFLATION
 Ineffective seal with respiratory tract /GIT
 PPV fails when seal is < 10-15 cm of H2O
 Airway protection from above the cuff fails when
seal is less than 15 cm H2O

63. BITE BLOCKS
 To prevent compression of tube and damage to
teeth
 In edentulous patients stability is improved
Ideal bite block:
 Should prevent tube occlusion and dental damage
 Should be easy to insert and remove
 Not stimulate or traumatize the patient
 Should not disturb the position of LMA

64.  Rolled gauze serves the purpose well
 Guedel’s airway is used but not recommended
 Best location : between back teeth as front teeth
are easily damaged if biting occurs during removal

65. FIXATION(RAM’S HORN FIXATION
TECHNIQUE)

66. ASSESSMENT OF FUNCTION
 Ventilatory capability
-observation of thoraco abdominal movement
-capnography
-auscultation of neck and chest
-peak airway pressure(should be low and not
associated with leaks)
-maintenance of oxygen saturation
-expired tidal volume( quantitative)

67.  Efficacy of seal with respiratory tract
a rough rapid idea about periglottic seal can be
obtained by squeezing the reservoir bag and noting
the pressure at which an oropharyngeal leak occurs
 Efficacy of seal with GIT
epigastric auscultation does not usually provide
information about the hypopharyngeal seal because
most air leaks occur into the mouth rather than
esophagus
for PLMA it can be assessed by testing for airleaks
upto the drain tube

68. CLINICAL INDICATORS OF CUFF
POSITION
 Quality of insertion
 The length,orientation and movement of the tube
 Inspection of the mouth
 Observation of the neck
 Assessment of function
 Drain tube airleak and patency test( for PLMA)

69. NON - LARYNGEAL MASK AIRWAYS
 Oesophageal combi tube
 Laryngeal tube airway
 Laryngeal tube airway suction
 SLIPA
 Pharyngeal X Press
 Perilaryngeal airway
 Elisha
 I-gel

70. OESOPHAGEAL TRACHEAL
COMBITUBE
 Developed by Dr Frass in Austria in 1980’s,
 though prototype of the invention was developed in the 1960s by
Drs. Don Michael, Lambert (of the Lambert-Eaton syndrome),
and Mehran.
 Disposable double lumen tube (tracheal & pharyngeal)
 With two inflatable balloons
 Pharyngeal lumen
 Blocked distally with a blue proximal standard 15mm connector
 Eight oval-shaped holes(7X3mm)
 Tracheal lumen
 Open at distal end
 Shorter, clear proximal portion with a standard 15mm connector

71.  Small adult ETC 37 F
 Large adult ETC 41 F
 CONTRAINDICATIONS
ABSOLUTE : complete airway obstruction
RELATIVE : disease of the esophagus and after the
patient has ingested caustic( if inserted without
visual check)
body size of the patient

72. INSTRUCTIONS FOR USE
 Free the upper airway of obstruction if
necessary(vomit,foreign bodies)
 Test the integrity of two cuffs
 Lubricate the tube
 Place the head in neutral position (positioning the
tube may be more difficult in sniffing position)
 Hold the tube above the proximal and below the
distal cuff and bend to 90 degrees for few seconds
 Open the patients mouth by inserting the thumb of
one hand deeply while pushing the patients tongue
forward.

73.  Introduce the tube slowly along the tongue till
the upper ring lies on the upper row of teeth.
 Inflate the proximal cuff with 80 ml of air
 Inflate the distal cuff with 10 ml of air
 Ventilate via the long tube.
 Check for position( auscultation of the
chest,ETCO2 monitoring)
 If positive-continue the same
 If negative- ventilate via the short tube
 If both negative the tube may have been advanced
too far

75. LARYNGEAL TUBE AIRWAY
 Shorter version of the Combitube with shaped seal
pharyngeal ends
 Cuffs inflated by a single line
 Latex free, double lumen with oropharyngeal and
oesophageal low pressure-cuffs
 Ventilation outlet in between and a second tube
placed posteriorly to the respiratory lumen

77. LTA WITH A DRAIN TUBE AND RESHAPED
CUFF IS KNOWN AS LTS

78. AIRWAY MANAGEMENT DEVICE
 Hybrid oesophageal tracheal combitube/laryngeal mask
airway intubator
 Translucent silicone tube
 Two silicone cuffs, inflated by separate pilot balloons
 Distal cuff when inflated occludes a small lumen
 Anteriorly facing oval ventilation orifice
 Resusable and can be steam autoclaved at 134 °C

80. 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)

81. PHARYNGEAL AIRWAY EXPRESS
 Non inflatable gilled conical tip at the distal end forms a
no pressure seal in hypopharynx,prevents regurgitation
and gastric insufflation
 Distal half of the vent has three vertical gills to prevent
airway obstruction
Advantages
 It is a sterile, single use latex free device
 Accommodates up to a 7.5 mm ID TT

83. SLIPATM
 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

85. ELISHA AIRWAY DEVICE
 It is unique as it combines three functions; ventilation,
blind and/or fiberoptic-aided intubation without
interruption of ventilation and gastric tube insertion
 New reusable device and is made up of latex-free
medical-grade silicone

86. I-GEL
 Anatomical seal of pharyngeal, laryngeal and perilaryngeal
structures
 Latex free, cuffless, easy to insert, single use
 Soft gel like material – thermoplastic elastomer
 Separates resp & GI tracts
 Minimal tissue compression

88. COMPLICATIONS
 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

89. CONTRAINDICATIONS
 ABSOLUTE
cannot open mouth
complete airway obstruction
 RELATIVE
increases 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

90. 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

91.  Cuff should be deflated immediately prior to
autoclaving as spontaneous reinflation occurs over
a few hours
 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.

92.  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

93. Thank you