1
ALTOONA REGIONAL HEALTH SYSTEM
DEPARTMENT OF ANESTHESIOLOGY
STANDARD OF PRACTICE
Date:
Effective Date:
16.November.2006
1.December.2006
Subject:
Use of the Flexible Laryngeal Mask Airway (FLMA) for
Adenotonsillectomy
To ensure patient safety during FLMA use for Adenotonsillectomy
To provide maximal surgical exposure and ensure adequate
ventilation of the patient undergoing adenotonsillectomy when a
FLMA is chosen for airway management
Purpose:
Policy:
Evidence-Based practice:
The safe use of the Laryngeal Mask Airway (LMA) for
otolaryngologic suregery is well established . Numerous literature
sources report several advantages of LMA use over the standard
ETT when used for these procedures. These include:
-Decreased incidence of laryngospasm
-Decreased incidence of aspiration
-Decreased incidence of post-operative coughing
-Decreased blood loss
-Decreaesd retching and straining on emergence
-Decreased SNS stimulation with insertion and emergence
-Decreased incidence of sore throat
-Decreased incidence of desaturation on emergence
-Decreased incidence of sore throat
-Avoidance of the need for muscle relaxation
-Avoidance of laryngoscopy
-Better tolerated at lighter levels of anesthesia
Practice Reommendations:
The Flexible LMA is quite suitable for ENT surgery as it less
likely to be kinked or obstructed and easily accomodates changes
in head and neck position. The same contraindications for use as
the LMA apply for the FLMA. It is also suggested that LMA use
should be avoided in patients who have been diagnosed with
Obstructive Sleep Apnea.
1. Maintain constant communication with surgeon through the
entire case.
2
2. Use a size smaller than predicted as use of too large an LMA
whill impair surgical access to the lower pole of the tonsil.
3. Insert FLMA after inducing an adequate depth of anesthesia.
Laryngospasm is almost always the result of an inadequatrely
anesthetized parient.
4. Pilot tube and shaft should be introduced and secured midline.
5. Lubricate the groove of tongue blade of Boyle-Davis gag or
lubricate the shaft of the FLMA to prevent the groove of the
tongue blade from catching on the shaft of the FLMA and
dislodging it.
6. Vigiliantly monitor ventilation during mouth gag insertion.
7. If the FLMA is properly inserted, the cuff should not be
visulaized after the surgeon has inserted the Boyle-Davis
mouth gag. The surgical view should be indistinguishable from
an endotracheal tube.
8. Orally suction before FLMA removal.
9. Consider leaving FLMA insitu until return of protective
reflexes.
10. Remove FLMA with cuff inflated to facilitate removal of
blood, secretions, or surgical debris on the dorsal surface of the
FLMA.
References:
1. Ahmed, M.Z., Vohra, A. (2002). The reinforced laryngeal
mask airwar (RLMA) protects the airway in patients
undergoing nasal surgery-an observational study of 200
patients. Canadian Journal of Anesthesia; 49:8, 863-866.
2. Birt, L.L., Yun, Elizabeth, E.S., Springman, S.R. (2001). The
flexible laryngeal mask airway (LMA) for outpatient pediatric
adenotonsillectomy surgery. Anesthesiology. 95:A 1220.
3. Hern, J.D., Jayaraj, S.M., sidhu, V.S., Almeyda, J.S., O’Neill,
G., Tolley, N.S. (1999). Clinical Otolaryngology. 24(2), 122125.
4. Nair, I., Bailey, P.M. (1995). Review of use of the laryngeal
mask in ENT anesthesia. Anaesthesia. 50, 898-900.
5. Patel, A. (N.D.). LMA flexible training. Royal National Throat
Nose & Ear Hospital, London. 1-14.
6. Ruby, R.R.F., Webster, A.C., Morley-Forster, Dain, S. (1995).
Laryngeal mask airway in paediatric surgery. The Journal of
otolaryngology. 24(5), 288-291.
7. Williams, P.J., Bailey, P.M. (1993). Comparison of the
reinforced laryngeal mask airway and tracheal intubation for
adenotonsillectomy. British Journal of Anaesthesia. 70, 30-33.