Airway Emergencies - special techniques

Laryngeal mask airway

Release of cricoid pressure may be required to insert & to allow correct placement of LMA.
The standard LMA is easier to use than the intubating LMA, it also provides a conduit for intubating the trachea.
A size 6 ETT can be loaded onto a fibreoptic bronchoscope & passed into trachea via the LMA
Portex has recently put out a disposable LMA without laryngeal slits & a wider shaft. These features should facilitate the passage of an ETT into the trachea

A 6 .0 ETT fits through a 3 or 4 LMA and a 7.0 fits through a size 5 LMA-remove LMA adaptor first.
Once the FOB is in the trachea, the ETT can be passed through the LMA and into the trachea. If the LMA is left in situ, it will have to be sacrificed to avoid extubating the patient. Alternatively, the ETT can be passed through the LMA outside the patient while the FOB remains in the trachea as a guide for later passage of the tube.
A 90°anticlockwise turn may be necessary to pass the ETT into the trachea if it catches on the right arytenoid cartilage

30-50kg= ILM 3, 50-70kg=ILM 4, 70-100kg=ILM 5

lubricate posterior surface of ILM
Lubricated ETT passed through ILM and removed before patient insertion
Once ILM positioned in patient connect to circuit
commence IPPV with tidal volume < 8 ml/kg
manipulate ILM to produce best capnography trace ie long straight expiratory curve
Gently pass well lubricated ETT through LM do not force
Once positioned connect to circuit and confirm position with capnography

withdraw ILM 6 cm and reinsert

ETT will need to be passed 1.5cm beyond transverse mark

this allows FOB to travel forward unimpeded by the epiglottic elevating bar of the ILM

An airway device with two lumens and two cuffs
Tracheal lumen (blue, labeled 1)
Oesophageal lumen (clear, labeled 2)
2 syringes 140ml & 12ml
Gently insert the Combitube into the mouth and continue to depth marker. The distal oesophageal lumen will then be either in the trachea or oesphagus

Inflate blue oropharyngeal cuff with 85ml of air and the distal white cuff with 10-15ml of air
Attempt ventilation through clear oesophageal lumen and confirm ventilation with capnography. If this lumen is in oesphagus attempt ventilation through blue tracheal lumen and confirm with capnography.