Comments on the Laryngeal Mask Insertion Technique Presented in the New Advanced Cardiac Life Support Protocol
To the Editor:
The new 2000 guidelines for cardiopulmonary resuscitation and emergency cardiovascular care were published in August 2000.1 The laryngeal mask airway (LMA) was presented as an alternative airway.
We would like to comment on the illustration to insert the LMA. The picture depicts several classic mistakes made during the insertion of the LMA. These may lead to LMA malpositioning and inability to achieve an airway and ventilation.2 In the 2000 guidelines, the LMA is depicted with a semi-inflated cuff, held by the shaft with the left hand and introduced straight into the mouth. The correct LMA technique3 is based on a close imitation of the swallowing mechanism. Before attempting insertion, the LMA cuff should be completely deflated and lubricated. The LMA is held with the dominant hand. The hand holds the LMA like a pen, with the index finger placed at the junction of the cuff and the shaft, with the LMA opening oriented over the tongue. The LMA is passed behind the upper incisors, with the shaft parallel to the patient’s chest and the index finger pointing toward the intubator. The lubricated LMA is pushed into position along the palatopharyngeal curve, with the index finger maintaining pressure on the tube. The index finger is used to push the LMA in the final position. This insertion technique is not self-evident for the first-time user but is essential for correct insertion.
The LMA was developed by an anesthesiologist, Dr Brain, for operating room use, and it is widely used throughout the world. The LMA is relatively uncommon in the United States in the prehospital setting. However, the LMA is often used in prehospital settings outside the United States. Research has demonstrated that experienced clinicians can easily teach the inexperienced how to insert the LMA correctly.4 Real-life training for Advanced Cardiac Life Support providers will be done by instructors with little or no clinical experience with the LMA. The 2000 guidelines are misleading and may lead to difficulty and failure in using the LMA.
Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2000; 102 (suppl 1): I95–I104.
Brain A, Denman WT, Goudsouzian NG. Laryngeal Mask Airway Instruction Manual. San Diego, Calif: LMA North America Inc; 1999.
Brimacombe R, Brain AIJ, Berry A. Nonanesthetic uses.In: The Laryngeal Mask Airway: A Review and Practice Guide. Philadelphia, Pa: Saunders; 1997: 216–277.
We appreciate the careful reading of the 2000 Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care1 by Matioc and Arndt. Their comments about Figure 3, which depicts a laryngeal mask airway (LMA), emphasize several important points about insertion technique that are extensively illustrated in the LMA package insert supplied by the maker of the device and are taught by Advanced Cardiac Life Support (ACLS) instructors.
They are mistaken, however, in their assumption that the simple illustration is intended as a definitive set of instructions for “real life training” by ACLS instructors with “little or no clinical experience with the LMA.” Figure 3 is only intended to give readers a generalized view of the appearance, manner of insertion, and final anatomic position of an LMA. Neither the text nor the figure legend suggests that instructors or students are to learn proper LMA insertion from the single panel (B) in Figure 3 that depicts LMA insertion. Matioc and Arndt describe LMA insertion as an acquired, tactile skill that requires repeated, supervised, hands-on practice. We are in complete agreement on this point, as stated in the figure legend: “Providers should receive adequate initial training in the use of the LMA and should practice with the device regularly to optimize insertion rates and to minimize complications.”1
The 2000 guidelines provide the scientific evidence supporting or not supporting a particular clinical intervention. The LMA, a new, advanced airway adjunct, received a Class IIA recommendation for use in specific clinical settings by adequately trained healthcare providers. LMA insertion is a skill easier to learn and simpler to retain than tracheal intubation because LMA insertion does not require laryngoscopy and direct visualization of the vocal cords. The American Heart Association/International Liason Committee on Resuscitation recommendations may encourage healthcare systems with providers who previously lacked advanced airway adjunct capability to now use an LMA when responding to a cardiopulmonary emergency. It is important to note, however, that clinical use of an LMA is an act of medical practice requiring specific medical authorization. Learning about LMA insertion while becoming an ACLS instructor or attending an ACLS Provider Course is continuing medical education, with adults learning more about new techniques. There must be no misconception, however, that ACLS provider training in the use of an LMA constitutes either authorization for an ACLS provider to use the device clinically or certification that an ACLS provider has achieved a specific level of skill.
We share the enthusiasm of Matioc and Arndt for the LMA, but our ACLS instructors have multiple teaching and learning resources that go far beyond Figure 3. Detailed, well-illustrated booklets and package inserts from the LMA manufacturer are supplied with the devices and with LMA practice mannequins. In addition, the advanced airway station in Pediatric Advanced Life Support instruction offers a training video that demonstrates the LMA insertion technique of Brain, to which Matioc and Arndt refer. This excellent supplemental resource will be available to the entire American Heart Association training network.