Atlas LMA & Igel Talk

8/13/2019 Atlas LMA & Igel Talk

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ATLAS HOSPITALP.O BOX 1101, Postal Code : 133, MBD East,

RUWI. Sultanate Of Oman.

Phone: 24811706

Fax:24811812

Email: [email protected]
mailto:[email protected]:[email protected]


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HOSPITAL

LifeLongHealth

www.AtlasEra.


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During The Presentation

PLEASE: Put cell-phones on silent/vibrate mo

Take emergency calls outside. Maintain silence.

HOSPITALS


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Laryngeal Mask Airway (LMA) & I-g

An introduction

Dr Rajesh T Eapen

Specialist

AnesthesiaATLAS HOSPITAL

Ruwi


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For my Nursing Colleagues:

Speak tenderly to them.Let there be kindness in your face,

In your eyes, in your smile,

In the warmth of your greeting.

Always have a cheerful smile.Dont only give your care,

But give your heart as well.

Mother Teres

5


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Airway Management

?

?


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7


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Objectives: Identify the indications, contraindications and sid

effects of LMA use.

Identify the equipment necessary for the placemof an LMA.

Discuss the steps necessary to prepare for LMA

placement. Discuss the methods of LMA placement.

Identify and discuss problems associated with LMplacement.

Introduce I-gel

How to insert the I-gel


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doctorsudarshan

Dr. Archie Brain


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Introduction

The LMA was invented by Dr.Archie Brain at the LondonHospital, Whitechapel in 1981

The LMA consists of two parts:

The mask

The tube

The LMA has proven to be very

effective in the management ofairway crisis


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Introductioncontinued

The LMA design:

Provides an oval sealaround the laryngeal

inlet once the LMA isinserted and the cuffinflated.

Once inserted, it lies at

the crossroads of thedigestive and respiratorytracts.


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ROLE OF LMA IN ASAS DIFFICUL

AIRWAY ALGORITHMLMA has role in the management of difficult airway a

A) ventilatory device

B) as a conduit to aid tracheal intubation

The laryngeal mask airway, as a ventilatory device and/intubating conduit, can be placed into the ASA difficuairway algorithm in five places

1) As an intubation conduit in the awake intubation limb

2) As an intubation conduit in the non-emergency pathw

in anaesthetized patient.3) As an airway device in the non-emergency pathway ithe non-emergency pathway in anaesthetized patient.


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4) As an airway device in the emergencypathway ( CVCI of the algorithm)

5) As a conduit to endotracheal intubation in

the emergency pathway (CVCI)


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The laryngeal mask airway fits into the ASA algorithm on the management of

difficult airway in five places, as an airway (ventilatory device) or a conduit f

fiberscope.

Laryngeal Mask Airway and the ASA Difficult Airway Algorithm

Indications for the
http://journals.lww.com/anesthesiology/Fulltext/1996/03000/Laryngeal_Mask_Airway_and_the_ASA_Difficult_Airway.24.aspxhttp://journals.lww.com/anesthesiology/Fulltext/1996/03000/Laryngeal_Mask_Airway_and_the_ASA_Difficult_Airway.24.aspx


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Indications for theuse of the LMA

Situations involving a difficult mask (BVM)

May be used as a back-up device where

endotracheal intubation is not successful. May be used as a second-last-ditch airwa

where a surgical airway is the only remain

option.

Equipment for


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Equipment forLMA Insertion

Appropriate size LMA

Syringe with appropriate volume for LMA cinflation

Water soluble lubricant Ventilation equipment

Stethoscope

Tape or other device(s) to secure LMA

Preparation of the


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Preparation of theLMA for Insertion

Step 1:Size selection

Step 2:Examination of the LMA

Step 3:Check deflation and inflation the cuff

Step 4:Lubrication of the LMA

Step 5:Position the Airway


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Step 1:Size Selection

Verify that the size of the LMA

is correct for the patient

Recommended Size guidelines:

Size 1: under 5 kg

Size 1.5: 5 to 10 kg

Size 2: 10 to 20 kg

Size 2.5: 20 to 30 kg

Size 3: 30 kg to small adult

Size 4: adult

Size 5: Large adult/poor seal with size 4

Step 2: Examination


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Step 2:Examinationof the LMA

Visually inspect the LMA cuff for tears orother abnormalities

Inspect the tube to ensure that it is free o

blockage or loose particles

Deflate the cuff to ensure that it will mainta vacuum

Inflate the cuff to ensure that it does not l


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Step 4: Lubrication


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Step 4:Lubricationof the LMA

Use a water soluble lubricant to lubricate the LM Only lubricate the LMA just prior to insertion

Lubricate the back of the mask thoroughly

Important Notice: Avoid excessive amounts of lubricant

on the anterior surface of the cuff or

in the bowl of the mask.

Inhalation of the lubricant may resultin coughing or obstruction.

Step 5: Positioning


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Step 5:Positioningof the Airway

Extend the head andflex the neck

Avoid LMA fold over:

Assistant pulls the lowerjaw downwards.

Visualize the posteriororal airway.

Ensure that the LMA is

not folding over in theoral cavity as it isinserted.


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LMAInsertionTechnique


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LMA Placement

Carries prominentposition in ASA algorithm

Balloon partially inflated

Directed posteriorly and

upwards towards thepalate

Jaw thrust and sniffing

position may help

placement
http://www.youtube.com/watch?v=96e46PyARaUhttp://www.youtube.com/watch?v=96e46PyARaU


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LMA Insertion Step

Grasp the LMA bythe tube, holding itlike a pen as near as

possible to the maskend.

Place the tip of theLMA against the

inner surface of thepatients upper teeth


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LMA Insertion Step

Under direct vision:

Press the mask tipupwards against the hardpalate to flatten it out.

Using the index finger,keep pressing upwardsas you advance the maskinto the pharynx toensure the tip remainsflattened and avoids thetongue.


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LMA Insertion Step

Keep the neck flexedand head extended:

Press the mask into theposterior pharyngealwall using the indexfinger.


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LMA Insertion Step

Continue pushingwith your indexfinger.

Guide the maskdownward intoposition.


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LMA I i S


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LMA Insertion Step

Grasp the tube firmlywith the other hand

then withdraw your

index finger from thepharynx.

Press gently downwardwith your other hand toensure the mask is fully

inserted.

LMA I ti St


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LMA Insertion Step Inflate the mask with the

recommended volume ofair.

Do not over-inflate the LMA.

Do not touch the LMA tube

while it is being inflatedunless the position isobviously unstable.

Normally the mask should beallowed to rise up slightly out

of the hypopharynx as it isinflated to find its correctosition.

Verify Placement of the


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Verify Placement of theLMA

Connect the LMA to a Bag-Valve Mask devor low pressure ventilator

Ventilate the patient while confirming equbreath sounds over both lungs in all fieldsand the absence of ventilatory sounds ovethe epigastrium


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LMA PlacementVerify placement by ventilating

Check for good chest rise, EtCO2, andadequate tidal volumes

Check for leak if significant leak at around10cm H

2

O problematic

May try size larger or smaller

May try to inflate/deflate cuff to obtain betteseal

If difficulty passing may try inserting upsidedown and then flipping around

S i th LMA


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Securing the LMA

Insert a bite-block or roll of gauze to preveocclusion of the tube should the patient bidown.

Now the LMA can be secured utilizing thesame techniques as those employed in the

securing of an endotracheal tube.

LMA I nsertion


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LMA I nsertion

36

Problems with


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Problems withLMA Insertion

Failure to press thedeflated mask upagainst the hard palate

or inadequatelubrication or deflationcan cause the mask tipto fold back on itself.

Problems with


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Once the mask tip hasstarted to fold over, thismay progress, pushing

the epiglottis into itsdown-folded positioncausing mechanical

obstruction

Problems with


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If the mask tip is deflatedforward it can push down theepiglottis causing obstruction

If the mask is inadequatelydeflated it may either

push down the epiglottis

penetrate the glottis.


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he LMA Classic was first introduced in the U.K.in 1988 and in the U.S. in 1992 as an alternativeto the face mask.

Curved tube ( shaft) connected to an ellipticalspoon- shaped mask ( cup) at a 30 angle.

Two flexible vertical bars to prevent the tubefrom being obstructed by epiglottis.

An inflatable cuff

An inflation tube

Self sealing pilot balloon


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Clinical benefits:


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Clinical benefits:

More secure than a face mask

Allows single-handed ventilation

Rapid, blind insertion (no laryngoscopy)


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Wire- reinforced, reinforced LMA

It can be bent to any angle without kinking.

It is less likely to be displaced during head

rotation.

USE- Head n neck surgeries, surgeries ofupper torso.

INSERTION difficult to insert. A stylet is to

be inserted into the tube to stiffen it.


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PROBLEM Small diameter of the tube limits

the size of endoscope or tracheal tube that

can be passed through it.

Smaller tube causes increased resistence.

It is unsuitable for MRI.


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It has a short, curved stainless steel shaft

with 15 mm connector.Metal handle is securely bonded to the shaft

to facilitate one handed insertion, positionadjustment.

A v-shaped guiding ramp is built to direct thetube. Recommended in both difficult airway and

Resuscitation algorithm

Allows intubation with minimal head and

neck manipulation


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INSERTION- in neutral position.

one hand movement in sagittal plane


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one hand movement in sagittal plane.

is held by handle, parallel to patients

chest.

it is inserted with a rotational movement

along the hard palate and post pharyngeal

wall.

USES- TRACHEAL INTUBATION- by the tuberecommended by the manufacturer.

Blind intubation

Blind nasal intubation

Fiberscopic guided intubation

Light guided intubation

PROBLEMS WITH INTUBATION


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any pharyngeal pathology

- LMA FASTRACh tracheal tube is expensive.

smallest size 3 for 30 kg weight

intubation can not be done in less than this

weight.


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It is similar to LMA Fastrach in construction.

It has 2 built-in channels, one to convey lightfrom and the other to convey the image to

the viewer.

The fiberoptic system can be autoclaved.

The monitor is attached to the LMA-Ctrachvia a magnetic latch connector.

Sizes- 3,4, 5.

USE- It is lubricated and inserted without

viewer attached, airway secured, ventilated

then viewer attached.


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Introduced by Dr. Archie Brain in 2000.

Has two separate tubes that effectivelyseparate the GI and respiratory tracts.

Three dimensional inflation of cuff

Holds a better cuff seal pressure.

Drainage Tube- helps to eliminate theaperture bars and to facilitate gastric tube

insertion.

The PLMA airway tube is flexible and wire

reinforced. It has built-in bite block at theroximal end.


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It is a sterile, disposable product made up of

PVC.

It has a special built-in curve which

correspondes the natural human anatomy.

NO aperture bars. It is an alternative of face mask for achieving

and maintaining the airway.

The cuff is flexible and tip is reinforced.

These facilitate insertion and also preventthe tip from folding.

LMA generally demonstrat


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g y

Ability to be placed without dvisualization

Better cardiovascular stabilityduring insertion and removal

Minimal IOP and ICP change Provide little protection again

aspiration

C/I in full stomach patients

Summary


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y Recent studies suggest that the LMA is an

airway device that paramedics adapt torapidly. Paramedics have proven themselvvery successful in the placement of the LM

Though endotracheal intubation remains tdefinitive technique for securing an airwaythe pre-hospital setting, it is believed that LMA may help in a small percentage of

patients who prove to be difficult to intubaendo-tracheally.


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Single use, cuff-less

Integral gastric channel

Epiglottis blocking ridge

Moulding feature


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Insertion Technique


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Insertion Technique.con


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I Gel Insertion


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I Gel Insertion


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Finally Remember:


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Atlas LMA & Igel Talk