Transport Safety with LMA Without PEEP
Yes, transporting a patient with an LMA without PEEP is dangerous and should be avoided—the most critical guideline evidence mandates that supplemental oxygen must be administered during transport when an airway device remains in place, and continuous monitoring with trained personnel is required, but PEEP itself is not specifically required during transport. 1
Critical Safety Requirements During Transport
The primary danger is not the absence of PEEP per se, but rather inadequate oxygenation, monitoring, and supervision during transport with any supraglottic airway device:
Supplemental oxygen administration is mandatory during patient transportation when an LMA remains in place, as recommended by the American Society of Anesthesiologists. 1
Continuous pulse oximetry monitoring must be maintained throughout the entire transport period when an airway device is in place. 1
One-to-one observation by appropriately trained staff must accompany the patient during transport, with an anesthetist immediately available. 1
100% oxygen should be delivered via the LMA throughout transport to maximize oxygen reserves and prevent hypoxemia. 1
The PEEP Question Specifically
While lung-protective ventilation guidelines strongly recommend avoiding zero end-expiratory pressure (ZEEP) during mechanical ventilation in the operating room, the transport context differs:
Intraoperative ZEEP is not recommended because it causes loss of end-expiratory lung volume, increased atelectasis, and decreased respiratory compliance. 2
During emergence and extubation, avoiding apnea with ZEEP is recommended to prevent rapid alveolar collapse. 2
However, research evidence shows that PEEP with LMA during spontaneous ventilation does not improve oxygenation in healthy patients, suggesting the benefit may be limited outside of controlled positive pressure ventilation. 3
PEEP of 8 mbar with LMA during positive pressure ventilation did not increase gas leakage overall but did require more frequent LMA reseating attempts, while providing only marginal improvement in oxygen saturation (98.5% vs 98.0%). 4
The Real Dangers of Transport Without Proper Precautions
The evidence reveals that the actual risks during transport relate to:
Loss of airway patency during the period between deep anesthesia and full awakening, which is high-risk for respiratory complications. 5
Hypoxemia from inadequate oxygen delivery, not specifically from absence of PEEP. 1, 6
Lack of immediate intervention capability if airway obstruction or laryngospasm occurs. 1
Inadequate monitoring allowing undetected desaturation. 1
Practical Transport Protocol
If transport with LMA is unavoidable:
Administer 100% oxygen via the LMA throughout transport. 1
Maintain continuous pulse oximetry monitoring. 1
Ensure trained personnel accompanies the patient. 1
Have the anesthetist immediately available upon arrival. 1
Insert a bite block to prevent LMA damage. 1
Position the patient appropriately, typically upright if tolerated. 1
Critical Caveat
The safest approach is to remove the LMA before transport using proper deep extubation technique with adequate anesthetic depth, oropharyngeal suctioning, and 100% oxygen delivery, followed by continued oxygen supplementation and airway supervision during transport. 5 This eliminates the risks associated with maintaining a supraglottic airway device during the vulnerable emergence period.
The danger is not primarily about PEEP absence—it's about transporting a patient with a supraglottic airway during emergence without proper oxygen delivery, monitoring, and trained supervision. 1