The Intubating LMA (Fastrach)

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This Skill Station covers:

-Use of the ILMA for blind intubation

-Use of the ILMA using fibre optic guidance

-The indications, contraindications, and complications of the ILMA and its role in the DAS guidelines

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The ILMA is used in Plan B of the DAS guidelines (the “can’t intubate can ventilate” situation). Outside the DAS guidelines, they can also be useful in the elective management of the known difficult airway and in patients with C-spine injuries. In the latter group, fluoroscopic and ultrasound studies have demonstrated decreased movement of the cervical spine with the iLMA than direct laryngoscopy with manual in-line stabilisation.^1,2

Fibre-optic guidance is the gold standard, but when used correctly, blind techniques have a success rate of greater than 90%:

• Blind insertion in patients without difficult airways: 95.7%.³
• Blind insertion in patients with known or anticipated difficult airways: 64% first pass, 92% overall, other 8% achieved with fibreoptic technique.⁴
• In unanticipated difficult airways: one study of 23 patients – 75% first pass blind insertion, 100% overall insertion.⁴
• Using the blind technique, oesophageal intubation may be up to 5%.⁵
• Fibreoptic technique improves first attempt success rate,⁴ overall insertion success rate,⁶ and nearly always succeeds when blind technique fails.⁷

A learning curve of about 20 insertions has been described,⁸ and studies with novice users suggest that high success rates can be achieved with minimal training.^9,10

Standard Mallinckrodt PVC tubes can be used successfully with the device,¹¹ and if used, should be inserted in the reverse orientation (against its natural curve), as this decreases the angle of emergence of the device and improves insertion rates.¹²

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-If using cricoid pressure, reduce or release this when inserting the ILMA

-Failure to pass TT commonly means:

-ILMA too deep – try withdrawing device slightly / smaller size ILMA

epiglottis folded over – try withdrawing ILMA 4 – 5cm then reinserting

-ILMA misaligned – try Chandy manoeuvre

-Inadequate depth of anaesthesia / relaxation

-Wrong head and neck position – head should be neutral

-ILMA can be reinserted (over TT left in place) for extubation to facilitate recovery and airway maintenance or enable deep extubation

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[az_lightbox_video animation_loading=”yes” animation_loading_effects=”scale_up” title=”ILMA – The Video” image=”334″ link_url=”https://vimeo.com/121029670″]

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1. Sahin A, Salman MA, Erden IA, Aypar U. Upper cervical vertebrae movement during intubating laryngeal mask, fibreoptic and direct laryngoscopy: a video-fluoroscopic study. European journal of anaesthesiology. 2004;21(10):819-823.
2. Gercek E, Wahlen BM, Rommens PM. In vivo ultrasound real-time motion of the cervical spine during intubation under manual in-line stabilization: a comparison of intubation methods. European journal of anaesthesiology. 2008;25(1):29-36.
3. Caponas G. Intubating laryngeal mask airway. Anaesthesia and intensive care. 2002;30(5):551-569.
4. Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A. Use of the intubating LMA-Fastrach in 254 patients with difficult-to-manage airways. Anesthesiology. 2001;95(5):1175-1181.
5. Dimitriou V, Voyagis GS. Blind intubation via the ILMA: what about accidental oesophageal intubation? British journal of anaesthesia. 1999;82(3):478-479.
6. Pandit JJ, MacLachlan K, Dravid RM, Popat MT. Comparison of times to achieve tracheal intubation with three techniques using the laryngeal or intubating laryngeal mask airway. Anaesthesia. 2002;57(2):128-132.
7. Joo HS, Kapoor S, Rose DK, Naik VN. The intubating laryngeal mask airway after induction of general anesthesia versus awake fiberoptic intubation in patients with difficult airways. Anesthesia and analgesia. 2001;92(5):1342-1346.
8. Parr MJ, Gregory M, Baskett PJ. The intubating laryngeal mask. Use in failed and difficult intubation. Anaesthesia. 1998;53(4):343-348.
9. Timmermann A, Russo SG, Crozier TA, et al. Laryngoscopic versus intubating LMA guided tracheal intubation by novice users–a manikin study. Resuscitation. 2007;73(3):412-416.
10. Levitan RM, Ochroch EA, Stuart S, Hollander JE. Use of the intubating laryngeal mask airway by medical and nonmedical personnel. The American journal of emergency medicine. 2000;18(1):12-16.
11. Kundra P, Sujata N, Ravishankar M. Conventional tracheal tubes for intubation through the intubating laryngeal mask airway. Anesthesia and analgesia. 2005;100(1):284-288.
12. Zhu T. Conventional endotracheal tubes for intubation through the intubating laryngeal mask airway. Anesthesia and analgesia. 2007;104(1):213; author reply 213-214.

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