LMA Placement for the Non-Jedi


A lot has been written about placing LMAs successfully…and I mean A LOT!  And just from my brief researching for this post (i.e. Googling), there seem to be at least as many ways promoted as being the “correct” or “The Best Way™ to put in an LMA as there are airway experts in the field of anesthesia.

My own method of LMA placement involves using my belly muscle to secure the patient’s head in modified sniffing position…a technique that henceforth will be known as “The Third Hand©”.  But I find that it requires an inordinate amount of Surgilube, so I’ll admit that it’s not the most cost-effective practice…although apparently, it is kosher.  [Attention Surgilube Corporate: Contact me if you want to talk about subsidizing/enabling my Surgilube habit.]

So rather than cover all the other anecdotally successful ways I have put in LMAs, I think it would be infinitely more constructive if I put down the big picture ideas and goals that sort of run through my mind when I’m emptying all the Blue Bells of all the Surgilube I can find for my next case.  First of all, let me just say that when it comes to LMAs, I realize that it’s a blind placement and that it does not “secure the airway” the way anesthesiologists mean when they say “The patient’s airway was secured.”  So if you’re the kind of person who lives by the gold standard of airway protection, maybe this discussion won’t change your practice much.  But if you’re like me (belly muscle notwithstanding) and over 300 million satisfied patients, there are a couple of key observations that I have made over the years that continue to inspire me to “do it the way I do it”.metal-tube-4-5oz

I had the pleasure of meeting the inventor of the LMA, Dr. Archie Brain, a few years back. He was doing a lecture series in the United States and agreed to come give a presentation on LMA development history to my residency class.  I found him to be such a modest and approachable person, lacking any sort of pretense that I would have almost expected of someone of his rockstar stature in the Halls of Anesthesia.  I was truly entertained by his recounting of how he made the first LMAs out of busted bicycle innertubes and old black rubber facemasks and rubber cement, thinking that this sort of inventiveness and pragmatic discovery simply wouldn’t pass muster in today’s heavily-regulated medicolegal environment.

Though I hadn’t progressed to using nearly as much Surgilube as I do today, I had put in enough LMAs as a CA-3 to be fairly competent and confident with my abilities.  But when Dr. Brain showed us photos and videos of his LMA self-intubation to demonstrate how agreeable LMAs are compared to awake intubation, at that moment my philosophy about LMA placement took a giant leap forward.  Until then, my LMA insertion method still consisted of scissoring open the patient’s jaw with my thumb and index finger, using a tongue depressor to displace the tongue into the floor of the mouth, and assisting the movement of the uninflated LMA over the hard palate and down the hypo pharynx with my first two fingers, as if I was trying to retrieve a fallen french fry between the driver’s seat and the center console of my car.


This is a series of photos from a February 1983 photoshoot documenting Dr. Brain’s insertion of an LMA into his own airway.  Unfortunately the money shots of Dr. Brain with the LMA going into his mouth and sitting comfortably in his airway were lost during one of his many traveling lectures.  True story of a world before PowerPoints and laptops!

At that moment, my own LMA insertion method could no longer be perfected according to the tectonic shift in my philosophy.  And it would be another decade or so before my Third Hand technique (read: belly muscle) would come into play.  But the mandate that I got from Dr. Brain’s presentation was clear:  If he could jam this big-honking hunk of plastic into his own unanesthetized airway with barely a gag reflex, and if LMAs are truly meant to be a “kinder and gentler” alternative to endotracheal intubation, then I should at least be able to replicate the fluid and effortless motion of inserting an LMA with the least amount of force into a patient who is asleep under general anesthesia.  Just because the patient is insensate with blunted gag reflexes does not give us license to use unnecessary force to get this thing to go in.  Indeed, it should be even easier and require less force with an asleep patient.  No matter what method you use to put in LMAs, think about this fact the next time you’re fumbling with one, flipping it this way or that, sticking your fingers into the patient’s throat, making the patient gag while your trying to get it in, or holding the patient down trying to keep him from pulling the LMA back out.  Seriously.  You’ve got to figure out a way to do it agreeably as if the patient were wide awake.

Do NOT be a Jedi when you are putting in an LMA.  There is simply no reason you should have to “Use the Force.”  Ever.

The second big influence leading to the discovery and confirmation of my own method of LMA placement involved the idea of successful vs. unsuccessful placement, including the factors leading to a high first-attempt success rate and the end-point measures of what an unsuccessful LMA placement might be.  We would probably all agree that a successful LMA insertion results in a well-sealed airway that leaks neither ventilation nor volatile anesthetic.  I would add that a positively superb LMA insertion allows for reliable and adequate positive pressure ventilation in various surgical positions if the purpose or need arises.  And seeking further end-point measures of success beyond simply airway patency, I like the idea of trying to at least qualitatively assess or include how traumatic the placement is.  The most specific (as opposed to sensitive) and objective (I don’t like the sore throat questionnaires) measure of LMA trauma that sounds reasonable to me is the presence or absence of heme on the LMA when you pull it out of a patient’s airway at the end of a case.  But in terms of incorporating this knowledge into a working method, nobody’s going to be there to see you pull the LMA out, so you’re on the honor system.  The overall idea is to achieve proficiency in whatever method you choose that allows a high first-attempt success rate with the least amount of trauma exhibited at the end of the case.  Here’s the journal article that I saw way back in the day that details some of these ideas:


Anyways, I hope some of this resonates with you out there.  Personally, I’m in awe of Archie Brain as an inventor, really, having met the guy and everything.  I spend a lot of time sitting in the operating room and thinking about things that need to be invented.  Wireless EKG is my Pie in the Sky.  But there’s other stuff, like a backboard for the sharps container or some sort of funnel that makes it more likely that stuff I throw in that general direction won’t end up on the floor.  I know Archie has spent his fair share of time staring at the ground keeping the seat warm, too.  Anyone care to hazard a guess on who invented these?????castrgard_2


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