What type of laryngeal mask airway (LMA) is recommended?

Recommended Type of Laryngeal Mask Airway

For airway rescue in critically ill adults and emergency situations, use second-generation supraglottic airways, specifically the ProSeal LMA (PLMA), LMA Supreme, or i-gel, with the PLMA offering the highest oropharyngeal seal pressure. 1

Second-Generation SGAs Are Mandatory for Critical Care

The British Journal of Anaesthesia guidelines explicitly state that only second-generation SGAs should be used in critically ill patients and airway rescue scenarios. 1 First-generation devices lack adequate seal pressures for poorly compliant lungs and increase gastric inflation risk. 1

Specific Device Hierarchy Based on Seal Pressure:

1. ProSeal LMA (PLMA) - Highest oropharyngeal seal pressure of all available devices 1
2. LMA Supreme (SLMA) - Second highest seal pressure 1
3. i-gel - Third in seal pressure performance 1

Key Distinguishing Features

ProSeal LMA advantages:

• Achieves seal pressures 8-11 cm H₂O higher than standard LMA across all cuff volumes 2
• Incorporates esophageal drainage tube that separates alimentary and respiratory tracts 3, 4
• Facilitates gastric tube placement in nearly 100% of cases (58/58 patients) 2
• Provides better protection against aspiration through dual-cuff design 3, 4
• Insertion over a bougie may improve placement success 1

LMA Supreme limitations:

• Narrow airway channel precludes easy use as conduit for fiberoptic intubation 1

Clinical Context Matters

For cardiac arrest: The American Heart Association suggests either advanced airway or bag-mask device, with no strong preference for specific LMA type in out-of-hospital settings with low intubation success rates. 1, 5 However, when an SGA is chosen, second-generation devices remain preferable.

For pediatric anesthesia: The French Society of Anesthesia and Intensive Care recommends supraglottic airways over endotracheal intubation for short-duration elective superficial surgery, with LMA use reducing perioperative respiratory complications by 2.94-fold. 6 Monitor cuff pressure ≤40 cmH₂O and limit insertion attempts to 3. 6

For ICU airway rescue: Second-generation SGAs must be immediately available wherever intubation of critically ill patients is attempted. 1 These devices enable oxygenation with PEEP, provide some aspiration protection, and facilitate fiberoptic intubation. 1

Critical Implementation Points

• Training is essential: Device-specific training improves success rates and should receive the same emphasis as tracheal intubation training. 1
• Maximum 3 attempts: Limit SGA insertion to one optimal attempt or maximum three attempts before declaring failure and moving to front-of-neck access. 1
• Avoid cricoid pressure: If cricoid pressure is applied during insertion, it should be relaxed or released as it impairs SGA placement and ventilation. 1

Common Pitfall

Do not use first-generation LMAs (standard Classic LMA without esophageal drainage) in critically ill patients, as they provide inadequate seal pressures (typically 20 cmH₂O vs 31 cmH₂O for ProSeal) and lack aspiration protection features. 2, 7 The ProSeal's additional dorsal cuff and esophageal vent represent essential safety features, not optional upgrades. 3, 4