Intubating Through LMAs
Dec 02, 2024
An airway adventure: Intubating through an LMA
With the development of second generation devices, LMA use in general anaesthesia continues to increase. Whilst they are safe and effective for the majority of cases they are used in, there are occasions where rapid conversion to a more definitive airway is required.
Converting from an LMA to an endotracheal tube can be a daunting task, as it is done infrequently and requires some technical skill and planning. Here’s what you need to know when it comes to intubating through an LMA:
๐ญ LMA type:
The type of LMA in use will determine your process and what equipment you need to gather.
๐ฌ Classic LMA: Intubation can still be achieved but requires a fibreoptic scope and an Aintree intubating catheter (these will be covered later in the month)
๐ก Second gen LMAs: More straightforward—intubation can be achieved blindly with an intubating catheter or a tube directly (with LOTS of lubricant), or under direct vision with a fibreoptic scope railroaded with a tube
๐ Fastrach LMAs: Specifically designed to facilitate blind intubation, with a set that includes a specific fasttrach tube and a pusher (note: Fasttrachs are no longer common practice)
๐ ๏ธ Equipment setup:
๐ฏโ๏ธ Intubation through an LMA is a two-person job, so make sure all required and backup equipment is available and within reach before starting
๐ If using a tube directly through an LMA, check the internal diameter of the LMA packaging—it needs to be bigger than the external diameter of the ETT
๐๏ธ If using Fastrach, ensure all equipment is from the Fastrach pack, as the LMA and tube are specifically designed to be used together
๐คนโ๏ธ Blind intubation through an LMA has a higher failure rate, so also prepare for standard intubation with a laryngoscope and/or videolaryngoscope
๐ข If railroading a standard ETT on a fibreoptic scope for intubation through a second-gen LMA, ensure the catheter mount has been removed from the tube as it will not fit through the LMA. Reconnect it once the LMA is removed
๐ If intubation through an LMA is required, there is likely clinical urgency and potential for rapid deterioration, so ensure an airway rescue trolley is present
๐ฌ Communication:
๐ค The key to successful intubation through an LMA is communication
๐ง๐ค๐ง It’s crucial that roles are clearly allocated, and constant communication and closed-loop feedback between the anaesthetist and assistant are maintained
๐ Each step in the process should be verbalised clearly and confirmed between the team before moving on
โก As with any airway procedure, alternative plans should be prepared in case of failure
โ
Build Knowledge
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Improve Safety
References:
Cook, T., Howes, B. (2011) Supraglottic airway devices: recent advances. BJA continuing education. V11(2) pp 56-61. https://doi.org/10.1093/bjaceaccp/mkq058
Simon, L.V., Torp, K.D. (2023) Laryngeal Mask Airway. Stat pearls. https://www.ncbi.nlm.nih.gov/books/NBK482184/#:~:text=The%20LMA%20Fastrach%2C%20also%20called,the%20way%20to%20facilitate%20intubation.
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