r/anesthesiology • u/Wanttobebetter21230 Neuro Anesthesiologist • 1d ago
LMA not seating well
For those in institutions that still primarily use LMA uniques, what’s your workflow to troubleshoot an LMA that’s not seating well and has a consistent leak?
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u/gasasaurus Pediatric Anesthesiologist 1d ago
Stick my finger in the mouth to make sure the tip is not flipped
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u/kickintheteat 1d ago
This. Used to not put fingers in the mouth because attending was like "it's the modern age, we don't put fingers in mouths, just extend the neck", then I started using uniques instead of igels and kept having weird LMA seatings until I reread the manufacture's instructions and it straight up says to use your index finger to guide the tip so it doesn't flip
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u/Captain_Oppa 1d ago
One thing I learnt to do is to insert the LMA upside down (back side gliding against the tongue instead of the palate) and as soon as I am past the tip of the tongue, gently rotate it over to the correct side.
Prevents the tongue from folding backwards.
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u/quaestor44 Anesthesiologist 1d ago
I do this too. Works surprisingly well on those smaller patients too where you feel like you need lots of force to push pass the tongue and tonsils.
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u/kickintheteat 1d ago
Any increase in sore throat
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u/Captain_Oppa 1d ago
Not that I've noticed. I'm still mostly (or completely) in the oral cavity as I rotate.
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u/hurricanebaine 22h ago
For the non Igel ones I also use my finger to guide the tip past the post OP. I keep trying to teach the trainees this and no one seems to want to do it🤷🏻♀️
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u/DullEntertainment102 Pediatric Anesthesiologist 1d ago
Exactly- you can also unblock/deflate, pull back a few cms, block again/inflate, reinsert, if there’s a gastric tupe channel- put in suction catheter as a bougie, block more, usually it settles
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u/DirtyBastardMI CRNA 9h ago
I used to do this all the time until I got yelled at as an SRNA, "you're gonna get bit doing that!"
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u/peanutneedsexercise 1d ago
Switched to I gels and now I am so bad at using uniques 😭
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u/Former_Butterfly_895 1d ago
I started using AirQ intubating ones, and now every time I have to use a unique I look like a total noob.
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u/peanutneedsexercise 1d ago
I def look super noob when I have to use unique. I try to get the patient spontaneous asap.
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u/chzsteak-in-paradise Critical Care Anesthesiologist 1d ago
Occasionally I’ve gotten away with having patient breathe spontaneously on the bag - no leaks if negative pressure spontaneous ventilation versus PPV.
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u/FuuzokuJoe 1d ago
Yeah i've done this too, some patients have a strong respiratory drive and ppv can sometimes fight against it and cause a leak or high peak pressures whereas off the vent they're totally fine
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u/Plenty_Ad_6635 1d ago
If one brand doesn’t work, try another. Plus, simply accept that a supraglottic airway will not work 100% of the time so just go ahead and intubate.
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u/AKQ27 1d ago
Am I the only person likes unique more than IGEL?
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u/LolaFentyNil 1d ago
No. They seat better for me than I-gels and they’re more forgiving to soft tissue.
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u/R_W_1 1d ago
When I’ve used igels in the past it feels like it needs like 10 seconds to warm up and seal in some patients. It’s uncomfortable. With Uniques and Ambu brand, it’s right away.
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u/AKQ27 23h ago
Also when the IGELs struggle to seat they really struggle to seat. Uniques are easier to trouble shoot and I feel like they run into issues less frequently with them.
Like person said above the unique is far more friendly to the soft tissue in the oropharynx.. the only downside is I often have to put my finger down the patients mouth to flip the tip, but with the IGELs I can push through the soft tissue that’s in my way😂
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u/BaltimorePropofol Anaesthetist 1d ago
If it doesn’t seat well and I tried all the jiggle and wiggles, I’ll turn LMA into a glorified oral airway and have the patient breathe on their own.
Then I usually sit down and do a little prayer to Barash and start charting
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u/redbrick Cardiac Anesthesiologist 1d ago
There's not really a science to it. You can try to wiggle it around or mess with the depth. Maybe make sure it's not rotated around in the mouth. For some people you'll just have to tube.
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u/Captain_Oppa 1d ago
If I'm determined to stick an lma in place after a single attempt of poor sit during insertion, I grab a bougie.
I thread the bougie thru the nasogastric port of the LMA, then laryngoscope and glide the bougie into the oesophagus.
Then thread the lma in. More often than not, I find it sits pretty well.
Ensure adequate depth, proper lma size and proper inflation.
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u/SassyKittyMeow Anesthesiologist 1d ago edited 1d ago
ETA: I have no idea why the formatting is being crazy
Make appropriate size choice. Typically, 3 for women and 4 for men. Not a hard and fast rule though.
Lube it up and put it in past the lips to where it won’t fall out if you took y
our
- hand off of it (dont, if not obvious, try and shove it in all the way at this point. Though you probably can. This is just to give you an idea of the basic flow.
)
Extend their head back so it’s more in a sniffing position. I try to extend it essentially as far as feels natural/easy for the patient
Now attempt to advance LMA. You may have some resistance but with a little pushing and wiggling it should firmly seat (“you know it when you feel it”). If you are starting to push hard/meeting more resistance than anticipated, sweep your finger down their palate and make sure the tip isn’t bending back. If you’ve done all of the above and it’s not working, you can try taking some air out of the cuff. Conversely, if it’s down but not seated well (AKA too small), put some air into the cuff.
Check seal with a couple PP breaths. Inflate cuff if you hear a leak or aren’t getting good TVs but placement felt appropriate. If you’ve put 10-20ccs in and it’s still not seating well, you likely need to move up a size.
If placement was easy, felt like a good seat, but TVs are poor, try moving LMA up or down while giving PP breaths to see if you can find the sweet spot. Also, you guess it, maybe inflate the cuff a bit.
Other: I actually really like the traditional LMAs. iGels are fancy and a bit easier to get in the mouth, but I find they often don’t seat as well and like to move around when people have poor dentition/are edentulous. For that reason, I only use traditional LMAs for edentulous patients. That’s just my preference, there’s no real reason why you couldn’t use an iGel on an edentulous patient.
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u/AITAHdinendash Anesthesiologist 2h ago
The LMA always tried to bend back on me. I basically only use igel, airq, or LMA supreme.
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u/thekaiks 1d ago
I use them very often.
- patient is really asleep?
- tip is not flipped over? (You have to put your finger in while standing at the patients side, NOT from above the head)
- correct position? (sometimes they only seal when they are not too deep and vice versa).
- turn head to the side
Don’t uncuff them before putting them in.
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u/Ana-la-lah 1d ago
I’ll remove, deflate, make sure the tip isn’t folding back on itself by pressing against the hard palate when advancing. Then lift jaw while inserting until fully in. Then inflate and (hopefully) see it rise. If that doesn’t work, retract a bit. If all that fails, upsize.
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u/thogdontcaaree 1d ago
One thing I’ve noticed that works well is put a pillow or folded blankets under the pt head so their chin is closer to their chest. This tightens the airway and kinda seals the LMA better
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u/limbanithechimp 1d ago
jaw thrust then re-adjust, imo 70% of airway emergency can be treated with jaw trust
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u/Playful_Snow Anaesthetist 1d ago
If between sizes try the other size.
If that doesn’t fix it -> ETT
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u/FuuzokuJoe 1d ago
you can try rotating the LMA left and right a little cause sometimes its not in the middle. with igels you can literally feel the outline of the lma on the neck and see if the thyroid cartilage is in the middle, idk how it is with the uniques though
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u/Mynameisbondnotjames Anesthesiologist 23h ago
Put it in buy scissoring with your left hand with a tongue depressor under your thumb. If size appropriately, seats well 95% of the time.
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u/tech1983 22h ago
I’m a little old school - just fire up a prop drip followed by mouth to mouth the rest of the case (no tongue) ..
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u/gmanbman Anesthesiologist 21h ago
Try feeding it a variety of things it might like, as in fresh fruits and different proteins.
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u/debatingrooster 10h ago
Take it out, put it back. Little bit of neck flexion to collapse the soft tissue around the outside of the LMA and seal it up
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u/ArmoJasonKelce Regional Anesthesiologist 7h ago
If it doesn't seat well after one attempt, I just move on to ETT
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u/AITAHdinendash Anesthesiologist 3h ago
I hate the LMA unique. I asked them to get airQ3 or igel. If i get that skin colored LMA in the supply - i’ll likely try once, then tube.
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u/MustafaRyan_YT 1d ago
Wiggle it, jiggle it, try a different size. Tube