Guided Insertion of the LMA ProSeal, a Comparison of Two Single Operator
Techniques
Allan J. Goldman M.D.
Department of Anesthesiology, University of Washington, Seattle, Washington

Introduction: The LMA ProSeal™ (PS), introduced in 2000, is designed to isolate the respiratory tract from the alimentary tract, and to provide higher inspiratory airway pressure than the LMA Classic (C) during positive pressure ventilation. Besides expanding the use of the LMA into areas where the Classic would be relatively contraindicated, there have been several case reports where the PS has rescued the airway in“cannot intubate/cannot ventilate” patients, for whom the LMA Fastrach and the fiberoptic bronchoscope (FOB) were unsuccessful (1,2). Of note, in both reports the patients were diagnosed with lingual tonsil hyperplasia (LTH) postoperatively. Ovassapian et al reviewed 33 patients with unanticipated failed intubation, all diagnosed afterwards with LTH. Routine physical examination of the airway did not identify its presence (3).
Some clinicians have noted that the PS to be slightly more difficult to insert than the C, with a first pass success rates of 82% vs 91% respectively (4). Brimacombe et al reported a Gum Elastic Bougie (GEB)/laryngoscope guided insertion of the PS with a 100% first attempt success (5). Pons et al also reported a 100% success rate preloading the PS with an orogastric (OG) tube (6), and using the standard‘Brain” insertion technique (without a laryngoscope).
Method/Results: How does one choose the best guided insertion technique? We have been practicing both techniques this past year on a daily basis, and indeed, they both have close to a 100% first attempt success with an experienced PS user. In contrast, the success rate is quite different in the hands of an inexperienced user. The inexperienced user maintains this high success rate with the GEB, while not with the OG. In a brief series (50 cases) with R2 anesthesiology residents, all with less than 5 previous PS placements, first time placement with the OG was 50%, but 100% with the GEB. We currently perform a single operator version of the Brimacombe GEB technique (see picture). The GEB is placed under direct visualization into the esophagus, the laryngoscope is removed, and the PS is inserted into position over the GEB in a classic Seldinger maneuver, using standard “Brain” insertion with the lubricated cuff flattened against the hard palate.
Conclusion: We currently recommend the OG insertion for routine cases, especially when planning to use an OG for the case. The GEB insertion is reserved as a backup technique, and as a first line technique in emergency situations, where rapidly securing the airway is essential. One must never forget the danger of perforating the esophagus, which carries a high degree of morbidity and mortality if not immediately recognized. The OG was designed for use in the esophagus, while the GEB was not. The ideal is to practice and learn the classic “Brain” technique of correct deflation and insertion.
We currently feel that the single operator GEB PS technique is an essential airway salvage skill. It is probably a safer option than the LMA Classic in the “cannot intubate or ventilate” patient at risk for aspiration. In these desperate situations, the stomach usually needs decompression. The “Single Operator GEB PS Technique” can be practiced regularly, is easy to learn for those with laryngoscopic skills, and can be mastered by those with poor LMA skills.
References:

1. Rosenblatt. The Use of the LMA-ProSeal in Airway Resuscitation. Anesth Analg 2003;97:1773-5
2. Dupanovic. Lingual Tonsil Hyperplasia and Failed Intubation; use of ProSeal LMA. S.A.M. Annual Meeting , Chicago, Ill Sept, 2004
3. Ovassapian et al. The Unexpected Difficult Airway and Lingual Tonsil Hyperplasia.
   Anesthesiology. 2002 July; 97 124-132
4. Brimacombe et al. A Multicenter Study Comparing the ProSeal and Classic LMA.
   Anesthesiology, V96, No2, Feb 2002
5. Brimacombe J, Keller C, Judd DV: Gum Elastic Bougie-Guided Insertion of the
   ProSeal Laryngeal Mask Airway Is Superior to the Digital and Introducer Tool Techniques. Anesthesiology 2004; 100:25-9
6. Pons VM, Madrid V; Ease Placement of the ProSeal with a Gastric Tube Inserted. Anesth Analg 2004;98:1816-17

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