A novel technique of flexible reinforced Laryngeal Mask Airway insertion.
Subject: Airway (Medicine) (Health aspects)
Airway (Medicine) (Research)
Disease transmission (Risk factors)
Disease transmission (Control)
Authors: Chakravarty, A.
Wadhawan, S.
Pub Date: 07/01/2009
Publication: Name: Anaesthesia and Intensive Care Publisher: Australian Society of Anaesthetists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 Australian Society of Anaesthetists ISSN: 0310-057X
Issue: Date: July, 2009 Source Volume: 37 Source Issue: 4
Topic: Event Code: 310 Science & research
Product: Product Code: 3841710 Anesthesia Apparatus NAICS Code: 339112 Surgical and Medical Instrument Manufacturing SIC Code: 3841 Surgical and medical instruments
Geographic: Geographic Scope: India Geographic Code: 9INDI India
Accession Number: 204614219
Full Text: The Flexometallic (wire-reinforced) Laryngeal Mask Airway (FLMA) is an extremely useful airway device, especially during head and neck surgery as it does not interfere with the surgical field and is resistant to kinking and compression when compared to the standard Laryngeal Mask Airway (LMA) (1). However, its insertion and correct placement can be difficult, owing to the floppy flexometallic shaft (2-4) whereby the force is not easily transmitted along the shaft. Therefore, methods of insertion as described for classical LMA may not be successful for the FLMA.

The finger insertion technique has the following disadvantages:

* it cannot be used in patients with limited mouth-opening, and

* the finger insertion technique may carry a risk of disease transmission to the personnel coming in contact with infected saliva of the patients.

Although the manufacturer's manual recommends digital insertion for FLMA, it can also be inserted using a variety of adjuncts such as a modified Magill forceps (2), stylet (3), the spatula introducer (4), Bosworth introducer (5) and the Flexiguide introducer (6). The disadvantages of these devices are trauma to the larynx with the forceps and stylet, rotation or displacement of the mask on removal of the stylet and reduced tactile feedback with the Bosworth introducer (4). Though the Flexiguide introducer, by virtue of a distal flange, reduces the tendency of the FLMA to rotate in the transverse plane during insertion, it does not completely prevent it6. Moreover the distal flange has a tendency to stick after repeated autoclaving (6).

Here we describe another possible adjunct for FLMA placement without using the finger insertion technique.

After fully deflating the cuff of the FLMA, the introducer of a Proseal LMA of the corresponding size can be used to conform the FLMA to its shape by placing its tip at the junction of the mask to the shaft and placing the shaft of the FLMA into the slot meant for the airway tube of the Proseal LMA (Figure 1). For added stability, the inflation tube of the FLMA can be wound around the introducer and secured to the introducer near the handle with adhesive tape. Now the dorsal portion of the cuff can be lubricated and the FLMA can be inserted by the standard technique described for the Proseal LMA. As with any LMA insertion, jaw-thrust can facilitate the insertion of the FLMA with this introducer. Thereafter the adhesive tape can be loosened, the inflation tube of the FLMA unwound and the introducer taken out. The cuff can then be inflated and positioning of the FLMA verified.


The method described here has the advantages that the transverse rotation of the FLMA is reduced, the Proseal LMA is a commonly used airway device and thus the availability of its introducer is not a problem, and costly equipment specifically designed for insertion of the FLMA is not required.


(1.) Dorsch JA, Dorsch SE. Laryngeal Mask Airways. In: Zinner S, eds. Understanding Anesthesia Equipment 4th ed. Pennsylvania: William & Wilkins, 1999. p. 463-504.

(2.) Welsh BE. Use of a modified Magill's forceps to place a flexible laryngeal mask. Anaesthesia 1995; 50:1002-1003.

(3.) Yodfat UA. Modified technique for Laryngeal Mask Airway insertion. Anesth Analg 1999; 89:1327.

(4.) Kil H-K, Koo B-N, Park J-H, Kim W-O. The spatula introducer for insertion of the flexible reinforced laryngeal mask airway (RLMA). Can J Anesth 2004; 52:117-118.

(5.) Bosworth A, Jago RH. The Bosworth introducer for use with the flexible reinforced laryngeal mask airway. Anaesthesia 1997; 52: 281-282.

(6.) Cook TM, Ford P, Craft TM, McCormick B, Ryder SA. An evaluation of the flexiguide introducer with the flexible laryngeal mask airway. Anaesth Intensive Care 2003; 31:193-195.



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