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International Journal of Medical and Health Research International Journal of Medical and Health Research ISSN: 2454-9142; Impact Factor: RJIF 5.54 Received: 09-08-2018; Accepted: 11-09-2018 www.medicalsciencejournal.com Volume 4; Issue 10; October 2018; Page No. 43-47...

International Journal of Medical and Health Research International Journal of Medical and Health Research ISSN: 2454-9142; Impact Factor: RJIF 5.54 Received: 09-08-2018; Accepted: 11-09-2018 www.medicalsciencejournal.com Volume 4; Issue 10; October 2018; Page No. 43-47 A review on laryngeal mask airway applications and limitations Sanjul Dandona1, Surinder Singh2, Neha Batra3 1, 2 Assistant Professor, Department of Anaesthesiology, VCSG Government Institute of Medical Science and Research, Srinagar Garhwal, Uttarakhand, India 3 Assistant Professor, VCSG Government Institute of Medical Science And Research, Srinagar Garhwal, Uttarakhand, India Abstract LMA is a widely used supraglottic air-way management device for anesthesia and airway support therapy for difficult-breathing in patients. LMA are significantly a primary choice for management of difficult airway in both hospital and out of hospital utilization. This device can be inserted blindly or with assistance of other technologies (light-wand, fiber optics, and endoscopy). However, disregard of a wide utilization, easy settings and a recommended airway management technique, it is of importance to acknowledge specific support data for their utilization, safety and efficacy in regards to patient’s safety. This review paper throws light on different LMA devices used. The review paper also discusses and highlights the advantages, disadvantages, complications and contraindications that are related with the use of this device during cardiopulmonary resuscitation (CPR), general anesthesia. Keywords: laryngeal mask airway, ventilation, airway management 1. Introduction face-masks for the maintenance of airway during operation British Anesthesiologist Archie Brain invented LMA or procedures. LMA’s haemodynamic stability and efficient, Laryngeal mask airway device in 1981with an intended emergent and enhanced recovery profiles are other reasons utilization in the operation rooms as an alternative ventilation. that made it a potential apparatus of choice for difficult airway LMA is a widely used supraglottic air-way management managements than endotracheal tube (ETT). The face-mask device for anesthesia and airway support therapy for patients failed to provide a proper support for setup in cases where with minimize occurrence of gastric-distention. LMA is not patients had beard or face-substructure was not helpful. only used as a substitute to face-masks and bag-valve-mask in Despite its popularity and wide-spread uses, there still exists a hospital’s operation theatre but also in pre-hospital stages and controversial issue for LMA’s established usage for positive- emergency treatments, additionally freeing up the hands of pressure-ventilations (PPV) or spontaneous breathing patients anesthesiologist [1, 2, 3, 4]. after failed intubations, unresolved disgorgement effects, etc. The device gained FDA (USA) approval for its commercial Although LMA use offers benefits of less gastric-distention use in 1991, since then it has been widely used and went than the bag-valve-mask ventilation, reducing the risk of through various additions and modifications. The LMA inspiration but not eliminating it [8-9]. Specific insertion avoids any obstructions of air-way into the oropharynx by methods, contraindications, complications and misplacement creating an air-tight seal across the larynx. It is an entirely issues associated with the LMA use are reviewed by us in latex free device comprising of an egg-shaped flattened mask, light of its advantages, disadvantages and indications for the an inflatable cuff that is connected to an airway tube. The air-way management during general anesthesia, maxillofacial mask cuff can form a self-seal on inflation by syringe recoil or or oral surgeries. balloon inflation methods. The LMA is designed in such a way that it fits in hypopharynx of the patient’s throat, isolating 2. The device the trachea while covering the supraglottic makeup. Generally One of the first constituent of LMA is a silicone mask of this device is placed on unresponsive and unconscious patents triangular shape and the design is based on the hypopharynx after administration of anesthesia. configuration. It also has an inflatable cuff on the inward The Laryngeal Mask Airway (LMA) gained much popularity mask's rim. A pilot tube which has a balloon situated on the among the anesthesiologists due to less training requirements tip is used to expand the cuff tube. It helps in the observing of and easy insertions. LMA for the maintenance of airway in the cuff pressure. A tube is fused at 30° edge to the back of spontaneous breathing patients is successfully used in the the mask. It connects the mask to the anesthetic circuit. A dark operating rooms while a low success rate of LMA line along the length of the tube corresponds to the mid- emplacements are observed in the emergency cases. The surface of the external aspect of the mask. Introduction of the basic aim behind developing LMA was to develop an dark line at both the 12 o'clock position and in the midline of alternative device that rendered efficient airway supports than the oral cavity indicates amend positioning of the LMA. endotracheal tubes (ETT) while being less invasive and Augmenting the laryngeal seal is reliant on getting and relieved hands of anesthesiologist unlike bag-valve-masks or keeping up the correct seating of the mask inside the 43 International Journal of Medical and Health Research hypopharynx. The device in inserted along the hard plate of optical-fibers and screen for direct laryngeal view. LMA airway conduit of patient in semi-sniffing pose. LMA then cTrach sets like LMA Fastrach. with single hand is rotated inwardly until the cuff tip rests at the opening of esophageal inlet. On positioning correctly the cuff is inflated to a optimal (~60mm of mercury) intra-cuff pressure. There are two vertical bars to air inlet which associates the tube to the mask. These bars keep the epiglottis from cabin against the tube opening and bringing about check of the gadget. To change the diverse age gathering and distinctive body measure, LMA come in grouped sizes. The LMA Classic is made of a delicate medicinal review silicone and is intended to be reused in the wake of autoclaving. Several modifications of the reusable and disposable LMA have been evaluated. Fig 1: Basic laryngeal mask airway design 2.1 Types of LMAs There are almost different types of LMA in use: (see figure 2) Fig 2: Various LMA types 1. LMA Classic: the original design with autoclave-able, reusable features is LMA Classic which is made up of 3. Application of laryngeal airway mask medical-grade silicone. The LMA has been utilized effectively for different surgical 2. Disposable LMA: disposable version of LMA, suitable for processes in pediatrics, including amid dental extraction. Less pre-hospitals insertions and emergencies is LMA Unique occurrence of hypoxia and fundamentally better arterial. oxygen saturation were found with the LMA. LMA has been 3. Other forms are the Portex Soft-Seal, LMA Fastrachand the subject of a few far reaching audits. The fame of the LMA the Ambu laryngeal mask (now called the AuraOnce). originates from its apparent advantages over other airway LMA Fastrach: an intubating LMA (iLMA), serving as in gadgets and a few investigations have demonstrated that intubation passage. Albeit, this could be achieved general achievement rate for the procedure and difficulty rate through all other designs of LMA, LMA Fastrach has no are low. The LMA, nonetheless, is frequently used in an limit to the ETT size and therefore, increases the success improper manner and there is a debate about recurrence of rate of intubation. Available in both disposal and non- fizzled arrangement, basic occurrences, for example, disposal forms, an epiglottic elevating bar for lifting of aspiration of gastric substance, especially in perspective of epiglottical passage, an anatomically curved rigid-shaft, proposals that the LMA may meddle with bring down and a handle for insertion are the salient features of LMA esophageal sphincter work. Trouble in review the glottis is for Fastrach. the most part insignificant for effective LMA position, making 4. LMA Flexible: another intubating LMA with soft tubing. it a valuable substitute airway. The curved tube directs the This type of LMA is generally not suitable for emergency instruments towards the glottis, making it a valuable purposes. intubation help. There are two application of LMA first one as 5. LMA ProSeal: in addition to airway management this type a ventilator gadget and other as a guide to blind/fiberscope- has an extra tubing for the suction of gastric content. It is guided tracheal intubation. The objectives of the specific not suitable for blind intubation and emergencies. LMA design were to remove the requirement for head and neck ProSeal also offers a 50% high pressure gain with no control and addition of fingers in mouth amid arrangement. leaks. The LMA Supreme, which is a newer design, is Setting up a safe airway in an injury persistent is one of the similar to the ProSeal and has a built-in bite block. essential basics of treatment. Any blemish in airway 6. LMA CTrach: another intuitive LMA design with built-in administration may prompt grave dismalness and mortality. 44 International Journal of Medical and Health Research Pressure support ventilation (PSV) pressure-targeted mode. endotracheal tube. Visual and facial nerve wounds related Another preferred standpoint of the utilization of PSV is that it with delayed face mask utilize are likewise stayed away from. requires less strain to get the objective tidal volume than The upsides of the laryngeal mask airway incorporate controlled mechanical ventilation. This lessened volume soporific administration, enlistment, support, and rise. The necessity results in less air spillage amid mechanical situation of the LMA can be refined without muscle relaxants ventilation with supraglottic aviation route gadget like the and laryngoscopy. The shirking of succinylcholine may laryngeal cover aviation route. Furthermore, the subsequent diminish the frequency of postoperative myalgias. Noteworthy decreased intrathoracic weight constricts the impact of and possibly negative hemodynamic changes related with both mechanical ventilation on hemodynamic and cardiovascular laryngoscopy and tracheal intubation are additionally lessened yield. It is evidenced that the sleeve of LMA can increase and are of shorter span with the utilization of the laryngeal the pressure onto the laryngopharyngeal mucosa adequately mask airway. In our examination, we excessively saw that high to cause lingual, hypoglossal or intermittent laryngeal LMA position can be proficient without muscle relaxants. nerve damage, or hinder venous and lymphatic seepage. Contrasted and an endotracheal tube, the soporific prerequisite Yearning because of gastro-esophageal-reflux (GER) and for resilience of the LMA has additionally been accounted for spewing forth remains a genuine potential issue in to be less. Contrasts in the reaction to the LMA are anesthetized patients. Brief pediatric surgeries not including likewise observed amid rising up out of anesthesia. The LMA the thorax or belly are frequently performed while the patients is all around endured, with a lower revealed rate of are breathing suddenly, especially with the across the board hyperactive respiratory events (e.g., hacking, laryngospasm, utilization of the LMA. It is in this way clinically pertinent to breath holding) than with an endotracheal tube. The anatomic know how anesthesia and opposition included by soporific arrangement of the LMA, with its absence of impingement on aviation route mechanical assemblies influence the WOB in the trachea and vocal ropes, limits inconveniences that are newborn children and youngsters. An over the top increment possibly connected with intubation. As per frequency of in WOB would increment respiratory muscle stacking and postoperative sore throat and additionally roughness is less oxygen utilization, and conceivably incline the patient to with the LMA contrasted and the endotracheal tube. respiratory muscle weakness and disappointment. A few examinations have proposed that LMA lessens WOB 3.2 Disadvantages contrasted and endotracheal tube. It has been guessed that On a first look LMA inclusion may resemble a simple method. anesthesia causes fractional upper aviation route impediment But, mistaken addition process represent a significant number coming about because of pharyngeal muscle unwinding and of the issues related with its utilization. Ideal position of the results in expanded WOB and that LMA diminishes WOB, as mask at the laryngeal delta permits gas exchange to happen contrasted and a veil without oral aviation route. Maxillofacial without deterrent and may likewise permit ventilation utilizing injury gives an unpredictable issue respect to the patients positive pressure. An inappropriately put LMA causes spillage aviation route. By and large, the patients experience of gas around the sleeve particularly when utilizing positive medical procedure for maxillofacial injury or for other, more pressure. Malposition of the LMA may not generally be serious, dangerous wounds, and anchoring the aviation route evident and an adaptable bronchoscope might be expected to is first in the presentation of general anesthesia. In such check the situation of the opening. The danger of gastric patients we envision troublesome endotracheal intubation and distension, gastroesophageal reflux, and tracheal dirtying mask ventilation. Likewise, the patient is generally viewed as might be expanded with off base situating particularly if having a "full stomach" and has not been cleared of a C-spine positive weight is utilized. A few investigations, in any case, damage, which may confound airway administration. The time have demonstrated that if a LMA was put appropriately, the accessible to achieve the errand is short and the patient's dangers of gastric enlargement, and gastroesophageal reflux condition may crumble quickly. Both decision making and were not expanded contrasted and an ETT. Trauma to the soft execution are disabled in such conditions. The laryngeal cover tissues is normal amid arrangement of the LMA and bleeding has a potential job in patients with troublesome airway, is much of the time watched while expelling the LMA. incorporating those with constrained mouth opening. Inappropriate strategy, folding of the tip of the LMA over itself, lacking anesthesia, applying superfluous power to LMA 3.1 Advantages is oftentimes an explanation behind these accidents. Barely The essential preferred standpoint of the LMA over the face- any other like Trauma to the uvula and the posterior cover amid general anesthesia incorporates the capacity to get, pharyngeal wall have been likewise been watched. A few secure, and keep up an unhindered airway. The laryngeal veil occurrences of nerve incapacitates including loss of motion of airway is passed past the tongue, shaping a seal with the the lingual nerve, hypoglossal nerve, glossopharyngeal nerve, laryngeal bay and taking out the most widely recognized and recurrent laryngeal nerve have been accounted for. reason for upper aviation route deterrent in the non-intubated Brimacombe et al. survey a significant number of these cases. tolerant. Upkeep of a patent airway with less scenes of oxygen Swelling of the tongue, cyanosis of the tongue, arytenoid de-immersion has been shown for the LMA as contrasted and cartilage disengagement, tem poromandibular joint separation, the face mask. Ecological inhalational gas presentation and vocal line brokenness have all been accounted for. At any esteems related with the utilization of a LMA have been rate a portion of these inconveniences might be credited to appeared to be not exactly those accomplished with a face high sleeve pressures or delayed length of utilization of the mask and tantamount to those with the utilization of an LMA. The rate of complications was 0.15% in a large 45 International Journal of Medical and Health Research study but the rate is likely to be higher in the emergency 5. Conclusion setting. Such complications include the following: LMA since it first advent in 1982, the device has been used  Mild sympathetic response safely on more than 100 million patients in last 40-50 years.  Local irritation LMAs continue to develop, modify and evolve with the  Conduit obstructing technical advancements. However it is necessary for  Complications associated with improper placement: anesthesiologists and clinical authorities to know the benefits Obstruction, laryngospasm and risks of their chosen airway management device for  Aspiration of gastric contents routine use. Although LMA is considered over other airway  Gastric distentions or ruptures support devices, it has its limitations and contraindications  Complications associated with positive-pressure that should not be ignored and an evidence based principle for ventilation : Pulmonary edema, broncho-constriction safety and efficacy should be preferably applied before their  Upper airway trauma: Pressure-induced lesions, nerve institutional purchases. It can be concluded that LMA may be palsies applied for such cases that need general anesthesia or sedation in shorter surgical. The genuine highlights and job of the The essential impediment and most prominent worry with the laryngeal mask will be set up just through more examinations utilization of the LMA is the failure to separate the airway and in which the gadget is utilized effectively. to ensure against the danger of yearning. In reality, the LMA has been appeared to shape an immediate conductor 6. References between the laryngeal bay and throat by encasing both. 1. Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Spewing forth and yearning have been accounted for with the Cohen NH, Young WL. Miller's Anesthesia E-Book. utilization of the LMA. The occurrence of spewing forth Elsevier Health Sciences, 2014. related with the utilization of the LMA changes from 0% to 2. Berry AM, Brimacombe JR, Verghese C. 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