lma proseal

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The LMA ProSeal

The LMA ProSeal is a reusable supraglottic airway device that incorporates a gastric drainagetube placed lateral to the main airway tube and which ends at the tip of the mask [12]. The

gastric drainage tube is designed to separate the gastrointestinal and respiratory tracts, allowing

regurgitated fluid to pass up the drain tube and bypass the glottis, thereby protecting the airwayfrom soiling in the event of passive regurgitation. An important additional design feature is that a

second, dorsally-located, cuff helps improve the airway seal, a particularly useful feature when

positive pressure ventilation is desired. These design features were intended to achieve a betterseal than an ordinary LMA permits, allowing patient ventilation using higher-than-usual airway

pressures, as well as to reduce the likelihood of aspiration (because of the gastric drain tube).

Figure 3 illustrates the device, while Figure 4 shows its correct anatomical positioning. A

disposable (single-use) version of the LMA ProSeal, known as the LMA Supreme, shouldbe also be available for commercial release as various national regulatory hurdles are addressed.

Besides expanding use of the LMA into clinical scenarios where the conventional LMA might berelatively contraindicated (e.g., obese patients), there have been several reports where the LMA

ProSeal has extricated patients from cannot intubate /cannot ventilate patients, where the LMAFastrach and fiberoptic bronchoscope (FOB) were unsuccessful [13].


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Figure 3.LMA ProSeal. In this illustration the term "Rear Boot" refers to the dorsal

(posterior) cuff described in this article. Image credit:http://www.sebac.fr/
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Figure 4. Illustration of the ProSeal LMA when correctly seated. Image credit: Keller C,

Brimacombe J, Kleinsasser A, Loekinger A. Does the ProSeal laryngeal mask airway preventaspiration of regurgitated fluid? Anesth Analg 2000; 91: 101720

Insertion of the ProSealTM LMA should be carried out following one of the

manufacturers three recommended insertion techniques:

Insertion using a special metal introducer instrument Insertion using an index finger Insertion using a thumb

Illustrated instructions for all three techniques are available online at

http://www.lmana.com/education-center/insertion-techniques.php In addition, video materialsto help with training are available from the manufacturer.

At least three malpositions for the ProSealTM LMA are known to occur: 1) insertion at aninsufficient depth, 2) insertion into the glottis, and 3) ProSealTM LMA tip folded backwards

behind the bowl against the posterior pharyngeal wall. Entry near or into the glottis may be

quickly recognized as follows: after insertion of the unit and cuff inflation one places a dab of

lidocaine gel or surgical lubricant at the end of the drainage port; with correct placement of the

ProSealTM LMA the gel should not bulge in and out with ventilation. Brimacombe and Kellerhave developed a proposed algorithm for the management of airway obstruction when using the

ProSeal LMA [14].

It has been reported that the LMA ProSeal is somewhat more difficult to insert than a

conventional LMA, with a first pass success rates of 82% vs 91% respectively [15]; this hasmotived some Individuals to study alternative insertion methods. For instance, Brimacombe et al.

reported that using a Gum Elastic Bougie (GEB)/laryngoscope guided insertion technique
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produced a 100% first attempt success rate [16]. In a similar vein, Martinez-Pons and Madrid

reported a 100% success rate by preloading the LMA ProSeal with an orogastric tube [17].

As noted earlier, the ProSeal LMA has helped expand supraglottic airway technology into

clinical scenarios where the conventional LMA might be relatively contraindicated, such as

obese patients, patients with gastroesophageal reflux, patients undergoing positive pressureventilation or patients undergoing laparoscopic procedures. This "paradigm shift" has been

discussed by Cook et al [18] and is illustrated in Figure 5.

Figure 5.Cook, Lee and Nolans proposal for modern airway management. Boxes represent use

of the airway. represents variation in individual practice or margin of disagreement. ImageCredit: T. M. Cook, G. Lee, and J. P. Nolan. The ProSeal laryngeal mask airway: a review of

the literature. Can J Anesth, 2005; 52: 739 - 760.

GOR = gastro-oral reflux; TT = tracheal tube; cLMA = conventional LMA; PLMA = ProSeal

LMA

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