Circulation 84,122 • Volume 23, No. 2 • Summer 2008   Issue PDF

Don’t Forget the LMA!

Davide Cattano, MD; Ivan Kangrga, MD, PhD

To the Editor:

We read with great interest several letters, editorials, and reports on airway management that appeared in the APFS Newsletters earlier this year.1,2 We think that some critical points were not addressed in these reports and that further consideration of this topic is warranted.

It seems that there has been considerable confusion and inconsistencies in interpretations of the Airway Management recommendations that originally appeared in 1993 and were revised more recently by the ASA,3 or by other international organizations like the Society for Airway Management (SAM) or by some expert collegue.4 These inconsistencies are present in literature and in our daily practice.

Although a clear message was sent by an excellent publication by Pressman,5 “Can’t ventilate? So please recover spontaneous ventilation,” it should be stated that this publication ignored other available resources and options for airway management.

As everyone knows, difficult ventilation is a scenario not so uncommon in the obese patient (when it is really obesity, not as proposed by a BMI 26 kg/m2),6 and a valuable resource has been recently re-outlined.7,8

The point is those resources and protocols to manage unpredictable difficult airway are right in our hands, or well, in our bags (bag “mask” ventilation, or better, bag laryngeal mask ventilation), whenever you decide to put your patient to sleep. The laryngeal mask airway is a valuable device, often underutilized by anesthesiologists. However, in centers with a significant prevalence of obese patients, the value of this device is fully recognized.

The real question is why do many anesthesiologists forget to rely on a laryngeal mask airway as a helpful tool in the difficult ventilation scenario? The device is an excellent emergency backup airway.

Moreover, in obese patients, it provides temporary airway management and allows for valuable time needed for preparation for a fiberoptic intubation.4,8

In addition, for some of us, it is actually the definitive airway used to deliver anesthesia safely and reasonably (with the ProSeal you can really even achieve high peak pressure).

Davide Cattano, MD
Ivan Kangrga, MD, PhD
St. Louis, MO


  1. Troop C. Difficult intubation in the obese patient. APSF Newsletter. 2005-06;20:83.
  2. Stasiuk R. Lessons from “can’t intubate/can’t ventilate” report. APSF Newsletter. 2006;21:58.
  3. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003;98:1269-77.
  4. Rosenblatt WH. The airway approach algorithm: a decision tree for organizing preoperative airway information. J Clin Anesth. 2004;16:312-6.
  5. Pressman MA. Return to spontaneous ventilation can be life-saving. APSF Newsletter. 2006;21:58.
  6. Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology. 2000;92:1229-36.
  7. Combes X, Le Roux B, Suen P, et al. Unanticipated difficult airway in anesthetized patients: prospective validation of a management algorithm. Anesthesiology. 2004;100:1146-50.
  8. Brodsky JB, Lemmens HJ, Brock-Utne JG, et al. Morbid obesity and tracheal intubation. Anesth Analg. 2002;94:732-6.