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Fixation of the ProSeal™ Laryngeal Mask Airway with a gauze bandage

The ProSeal Laryngeal Mask Airway (PLMA and Intavent Orthofix, Maidenhead, UK) allows a high seal pressure and provides a path for regurgitated gastric contents [1, 2]. However, to benefit from these advantages, attention must be paid to correct insertion and fixation techniques. Although the PLMA may initially be positioned correctly, with its tip fitting securely against the upper oesophageal sphincter, malposition may develop subsequently if the fixation method is inappropriate. Gupta & Ravalia [3] described inadequate ventilation with the PLMA and Brain & Verghese [4], in reply, explained why the author’s use of adhesive tape applied to the mandibular arch was inappropriate. In this position, the tapes cannot transmit the required inward force on the device, necessary to ensure its distal end remains pressed against the upper oesophageal sphincter. As a result, inspired gas may leak through the seal of the mask and into the oesophagus and out through the drain tube. Dr Brain advises use of the method shown in the instruction manual [5], in which the ends of the adhesive tape are applied to the maxilla, so that the device remains firmly pulled inwards while in place, ensuring an oesophageal as well as a laryngeal seal. The use of adhesive tape for fixation may have limitations. There may be allergy to the adhesive tape, its use may contra-indicated if the skin is burned or traumatised, if the skin is loose, as in the elderly, in the edentulous, or if there is facial hair. Figure 3 shows a modification of the well known method of ‘tying’ an airway device in place which has proved successful in such cases. A gauze bandage (or tying tape) is looped around the bite-block section of the outer end of the device and the ends are then brought between the two tubes over the outer end of the bite-block, after which they are tied around the neck. Using this method, the PLMA can be firmly anchored into position using the same principle as that employed when using the recommended adhesive taping method, as in both cases pressure is exerted in an inward direction. As well as avoiding the above disadvantages of adhesive tape, this method may offer greater control over the applied pressure, which should never be excessive. We thank Dr Archie Brain for his kind assistance with the manuscript.