20 ANESTHESIOLOGY NEWS GUIDE TO AIRWAY MANAGEMENT AUGUST 2009

THE SCIENCE BEHIND

POSITIVE PATIENT OUTCOMES
Introduction
The LMA airway has been used an estimated 200 million
times since its introduction in 1988 in the United Kingdom and
in 1993 in the United States.
1
Currently, laryngeal mask airways
(LMAs) are used in about 35% of all general anesthetic procedures
in this country.
2
Originally created as a hands-
free replacement for the face mask, the LMA has
gone on to replace endotracheal tubes (ETTs) as
the preferred airway in millions of cases each
year.
1
This remarkable shift in practice over the
last 20 years has occurred for a number of rea-
sons, including ease of placement, lower drug
requirement, reduced hemodynamic response,
reduced intracranial and intraocular pressure,
smoother emergence, and a lower incidence of
sore throat.
3
Given the inherent benefits of the LMA over
the ETTespecially after recognition that an
LMA can be used to ventilate patients safely
many clinicians have expanded usage of the
LMA to include longer cases, heavier patients,
patients with mild to moderate reflux, and
abdominal procedures. The recently released
LMA Supreme may offer improved options for
LMA-eligible procedures.
The LMA Supreme airway was introduced
in late 2007. It represents the most advanced
laryngeal airway yet developed by Archie
Brain, MD, inventor of the original LMA air-
way, the LMA Classic. The LMA Supreme is
a supraglottic airway device with the follow-
ing features: single use to alleviate concerns of
cross- contamination, an anatomic curve which
facilitates easy insertion, a drain tube to allow
gastric aspiration, a high volume/low pressure cuff which gener-
ates higher seal pressure, a built-in bite block and fixation tab
to help secure the airway, and an oval airway cross section for
improved stability of the airway once placed (Figure 1).
Anesthesiologists determine when to use an ETT or an LMA
based on patient types, procedure types, and patient positioning.
These factors often help the clinician establish a patients risk for
aspiration. Pulmonary aspiration of gastric contents is a rare but
serious complication of anesthesia. Studies suggest that the risk
for aspiration in terms of patient type is greater in heavier patients,
diabetics, and patients with mild to moderate gastroesophageal
reflux disease.
4
One new study suggests that even normal, fasted
patients may benefit from the routine use of the LMA Supreme over
other supraglottic airways.
The LMA Supreme:
Should gastric access be the standard of care?
Sean H. Tretiak, MD, MPH
Staff Anesthesiologist
Torrance Memorial Medical Center, Palos Verdes Peninsula
Plastic Surgery Center
Torrance, California
Figure 1. LMA Supreme.
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ANESTHESIOLOGY NEWS GUIDE TO AIRWAY MANAGEMENT AUGUST 2009 21
Supported and approved by LMA North America
Study Background and Purpose
This study was conducted at the Palos Verdes Peninsula Plas-
tic Surgery Center and Torrance Memorial Medical Center in
Torrance, CA, by Sean Tretiak, MD. The study included 23 con-
secutive, LMA-appropriate patients (general anesthetics with no
contraindications).
The plan was to assess patient benefits of using LMA Supreme
versus LMA Unique intraoperatively on airway seal pressure, ease
of placement, and (for LMA Supreme only) gastric aspirate. Vari-
ables including patient weight and anticipated airway difficulty
were analyzed to exclude them as causes of any differences found.
Twenty-three patients were assigned to one of the 2 groups.
Assignment was not purely random, in that it was affected by the
availability of the LMA Supreme, and only LMA Supremes were
used for laparoscopic cases (Table 1).
Evaluation Criteria
An observer personally administered care and evaluated each
patient and criteria point. Airway seal pressure was measured
in cm H2O using a stethoscope to the neck during a continuous
Table 1. Assignment by Procedure
Procedure Seal Pressure (cm H2O) Gastric Aspirate Volume (mL) Weight (kg)
LMA Supreme
Breast reconstruction 38 10 85
Knee incision & drainage 35 3 75
Partial mastectomy 40 15 70
Breast implant 32 3 90
Breast implant removal 39 100 86
Breast reduction 40 10 60
Laparoscopic tubal ligation 40 20 65
Saphenous vein ablation 40 15 110
Breast reconstruction 29 3 60
Breast reduction 40 10 77
Hip open reduction internal fixation 24 15 70
MEAN 36.1 18.5 77.1
LMA Unique
Umbilical hemorrhage 32 70
Presacral cyst 18 70
Breast reduction 31 85
Cystoscopy 40 151
Cystoscopy 40 65
Carpal tunnel surgery 21 89
Knee arthroscopy 25 90
Breast augmentation 40 70
Vasovasectomy 30 110
Breast implant 28 60
Dilation & curettage 10 95
Hydrocele 14 84
MEAN 27.4 86.6
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22 ANESTHESIOLOGY NEWS GUIDE TO AIRWAY MANAGEMENT AUGUST 2009
THE SCIENCE BEHIND
POSITIVE PATIENT OUTCOMES
bag-delivered breath. The maximum pressure tested was 40
cm H2O (to avoid pneumothorax), so any entry of 40 is actually
equal to or greater than 40. Cuff volume and LMA position were
optimized for the greatest seal pressure while still allowing effec-
tive ventilation. Patient weights were recorded in kilograms.
Another evaluation point of emphasis was the ease with which
airways were placed in patients. Two measures were used: the
number of attempts necessary to properly secure the device and
how easy it was to place the device. Ease of placement was a sub-
jective evaluation categorized as 1 of 3 assessments: simple, with
no special techniques needed; moderate, including possible special
techniques to properly place; and difficult, which included unsuc-
cessful attempts.
For each LMA Supreme, gastric aspirate volume was also mea-
sured. To accomplish this, a 14 French Salem Sump was inserted
immediately after LMA insertion and aspirated while being with-
drawn. Aspirate volume was recorded in milliliters. The gastric port
was left open to air throughout the remainder of surgery. Finally,
based on physical examinations and reviews of previous anesthe-
sia records, patients were anticipated to have either normal or dif-
ficult airways.
Study Conclusions
AIRWAY SEAL PRESSURE
The LMA Supreme had a significantly higher seal pressure than
the LMA Unique (36.1 vs 27.4 cm H2O). Furthermore, due to the
study design limitations with pressures only tested to a maximum
of 40 cm H2O, the real difference between the LMA Supreme and
the LMA Unique was likely even greater. Each entry listed as 40
did not leak at 40, but rather would have leaked at some number
greater than 40. There were 5 such patients in the LMA Supreme
group versus 3 in the LMA Unique group. In another study, Verghese
experienced a mean LMA Supreme seal pressure of 28.47 cm H2O
using very similar measurement techniques, including limitation of
Table 2. Comparison of LMA Supreme

With LMA Unique
LMA Supreme (n=11) LMA Unique (n=12)
Airway seal pressure (P=0.02) 36.1 cm H2O 27.4 cm H2O
Number of attempts 1.0 1.1
Ease of placement 1.2 1.1
Gastric aspirate 18.5 mL
Body weight 77.1 kg 86.6 kg
Anticipated airway difficulty 1.0 1.1
Numbers represent means.
measurement to a maximum of 40.
5
In reviewing that study, the
main difference in implementation of the LMA Supreme was a strict
inflation to a cuff pressure of 60 cm H2O. Cuff inflation pressure in
this study was not a controlled variableit was determined by best
seal pressure and was not measured. A future study could further
examine the relationship between cuff and seal pressures.
Clinically, having a seal pressure well over 30 cm H2O makes an
airway more suitable for positive pressure ventilation cases, since
it is rare outside of the critical care realm where higher pressures
than this value are needed.
2
Furthermore, the argument in favor of
LMA use to protect the airway is based on an effective seal of the
entire subglottic area from gastric contents (in contrast to the ETT,
which only protects below its cuff). A higher seal pressure increases
the protective benefits of the LMA Supreme. Table 2 shows the full
results of the study.
EASE OF PLACEMENT
Subjectively, the LMA Supreme seemed easy to place despite
the fact that this observer had placed less than 10 of them before
beginning the study. This is in comparison with over a decade of
experience placing the LMA Classic and the very similar LMA Unique.
Despite this, there was no difference found in ease of placement
with the various LMA airways. These results are similar to a pre-
liminary study published by Ferson et al who reported 96% and 98%
success rates for first and second insertion attempts, respectively.
6

This evidence supports the assertion that the LMA Supreme is easy
to place, despite its rigid shape which forces the user to implement
a traditional Brain technique in placement. Note that the tip of
the deflated LMA Supreme points more anteriorly than a deflated
LMA Unique, thus making it less likely to fold back on itself during
insertion (Figure 2).
GASTRIC ASPIRATE
It was not possible to aspirate gastric contents while the LMA
Unique was in place, so a comparison was not possible with the
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ANESTHESIOLOGY NEWS GUIDE TO AIRWAY MANAGEMENT AUGUST 2009 23
Supported and approved by LMA North America
LMA Supreme. The hypothesis concerned the vol-
ume of occult gastric contents (in nothing-by-mouth
patients having elective surgery), not that there
could be any difference caused by using a particular
airway. The 18.5 mL of gastric juices found on aver-
age was certainly more than expected. One patient
had 100 mL, which would certainly pose a threat
to a patient under general anesthesia. That patient
had no risk factors for gastroparesis and weighed
86 kg. A search of previous studies regarding intra-
operative gastric juice volume revealed a study by
Verghese who observed fasted, female patients
undergoing routine general anesthesia. Findings
were similar, with a mean volume of 16.25 mL and
a range from 5 to 124 mL.
5
BODY WEIGHT
This factor was considered mainly to exclude
weight as a cause of poor seal pressure, difficulty in
placing airways, or differences in gastric contents.
Because a significant difference was not found, one
can conclude that any differences in other variables
were not caused by weight.
ANTICIPATED DIFFICULT AIRWAY
This variable was considered mainly to exclude
anticipated difficult airway as a cause of poor seal
pressure, difficulty in placing airways, or differences
in gastric contents. Because a significant difference was not found,
one can conclude that any differences in other variables were not
caused by anticipated difficult airway.
Summary
The LMA Supreme is the latest iteration of LMAs quest for the
ideal supraglottic airway: a device that is easy to insert, and yet
separates the respiratory and alimentary tracts. Aspiration pneu-
monia, although rare, can have dire consequences. When the LMA
Supreme is correctly positioned, it may provide superior protec-
tion against aspiration. Even a fasted patient can have stomach
volumes placing them at risk for aspiration. Gastric access with the
LMA Supreme is easy to achieve. Devices that enable easy gastric
access are the future of supraglottic airway design, and their rou-
tine use may be an evolving standard of care.
References
Data on file. LMA North America, Inc. 2009. 1.
Verghese C, Brimacombe J. Survey of laryngeal mask airway usage in 11,910 2.
patients: safety and efficacy for conventional and nonconventional usage.
Anesth Analg. 1996;82(1):129-133.
Brimacomb JR, Brain AI. 3. The Laryngeal Mask Airway: A Review and Practical Guide.
London, England: W.B. Saunders Company; 1997.
Hagberg C. 4. Benumofs Airway Management. 2nd ed. Philadelphia, PA: Mosby; 2007.
Verghese C, Ramaswamy B. LMA-Supremea new single-use LMA with gastric 5.
access: a report on its clinical efficacy. Br J Anaesth. 2008;101(3):405-410.
Ferson DZ, Chi L, Zambare S, Brown D. The effectiveness of the LMA Supreme 6.
in patients with normal and difficult-to-manage airways. Anesthesiology.
2007;107:A592.
Figure 2. LMA Supreme properly inserted.
When properly inserted, the LMA Supreme forms 2 seals: one at the upper
esphageal sphincter and the other over the glottic opening.
Image courtesy of LMA North America.
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