hi everyone today I'm going to go through laryngeal mask Airways
also known as lmas or supraglottic Airway devices so let's get started
so the first disclaimer obviously patients who are hypoxemic or not ventilating well these are
high risk situations and the LMA again falls in the context of a whole plan for resuscitation so
first of all I like to give like with all my talks a strategy and a framework for the way that I'm
going to be approaching this so I imagine that Airway management is really trying to optimize
oxygenation ventilation through any of these means bag Mass ventilation intubation we've got a couple
of videos for that as well as the LMA now if these aren't working and we're in a can't intubate can't
oxygenate scenario then you'll be thinking of a surgical Airway or front of the access which is
a whole other topic as well and you'll definitely need to be calling for help and only doing things
that you're comfortable doing and know how to do it and also manage the problems and complications
that could occur so with that in mind let's get started with LMA ventilation so around your mask
Airway is really a device that just sits over the trachea and the laryngeal opening and this
then creates a seal which allows us to positive pressure ventilate so again just like the bag mask
or intubation your what you're doing is you're creating a seal with a certain structure and then
using positive pressure to ventilate through this tube and inflate the lungs so what I'm going to
do is I'm going to demonstrate on this area heavy model so again where I'm going to place this LMA
really is just sitting past the tongue with the opening and aperture just above where the chords
are and that way you'll get ventilation down this tube and into the airway so next we're going to
go through is insertion technique now that you've seen where the LMA sits in that anatomical model
you can probably make sense of what you need to do so essentially there's a couple of different ways
that you can insert this LMA but the most common one is to push it past the tongue straight back
so what I do is I usually open the head just like that so do a head tool that opens the mouth often
you can get your assistant so just open up the mouth like so and that allows you to place this
in you need the minimal aperture that you need is about two centimeters so just remember that if
you have a patient with very small limited mouth opening you'll need a low profile potentially like
a fast track LMA to make sure that you're able to get it through to two semi is probably the bare
minimum you need so I've got the mouth open I push it back now the first resistance you're going to
get is the tongue so you really sometimes you get a resistance there that doesn't allow you
to place it so what I have to do is I just need to apply a light bit of pressure and that then
sits correctly and you'll feel a bit of a pop and I rise in the larynx as that goes down so just to
demonstrate that insertion again I tilt the head back I might get an assistant to open the mouth
or even try to open it myself I push it past the teeth gently and then I'll push backwards so it
goes along the upper the hard palate and then down the soft palate past the tongue again sitting just
above the airway of the trick here which allows ventilation again as always I check ventilation
you can see the rise and fall of the chest and sometimes that's all you need other
times you'll inflate the cuff and there's it's already got some zones marked out
essentially you want to inflate that cuff and try to create a better seal [Music]
it's one of the common things that happens is that as you place the LMA in sometimes it just
gets stuck at the posterior pharynx so what you need to do is sometimes follow the curvature of
your hard and soft palate and then push it around the tongue so I'm actually forcing backwards with
a bit of pressure and that allows it to get past the tongue more easily that's one of the first
things I do again there's many ways that this can go wrong so really no matter what you're
doing you have to continuously assess that you're ventilating so rise and fall the chest and that
you're getting fogging in the tube and hopefully entitle CO2 Trace as well as the saturations are
appropriate and safe for this patient so let's say you're trained to put an element and you've
put that element in and you're trying to ventilate this patient but you simply can't ventilate for
example there might be an obstruction or it might be too great a leak so I've got a few things that
I can do and as I mentioned a few of my other videos the common things are I could position
the patient better or I can provide paralysis again paralysis can be very tricky you've got to
know how to manage the complications of paralysis before giving any of these very dangerous drugs
so positioning paralysis of ways I can optimize any of these Airway situations that specifically
for lmas just like with um you know having a mask on your face or an entry kill tube the
size and the type are mainly the things that I can ingest so this one I've got as a size four
if there's too much of a leak I can either use a size five elements to go up in size or put a
bit more air in the cuff generally speaking you want to go for a higher size and put less air
in the cuff that just minimizes the chance of trauma to the airway so if I've tried a
different size LMA it just doesn't seem to fix the problem I can then try a different type of
LMA whether it's a pro seal or supreme or an igel or one of the newer devices that will
be out in the market so thanks very much for watching this ABCs of anesthesia we've gone
through lmas the optimization the strategy how to troubleshoot so I hope that was interesting please
share with anyone who might be interested you'll see you next time foreign [Music]