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Optimal Use of LMA SupremeTM for Laparoscopy

This small randomized clinical trial of manometry guided cuff inflation [1] provides some useful data supporting safer use of the supraglottic airway device (SAD), the LMA SupremeTM, during laparoscopic cholecystectomy. The use of pneumoperitoneal distension provides potentially difficult conditions for lung ventilation and increased risk for possible aspiration of gastric contents. The author’s technique for cuff inflation, using manometry to measure and then adjusting the intracuff pressure to the Peak inspiratory pressure, and then increasing intracuff volume in small increments to allow leak free lung ventilation despite the increased impedance provided by pneumoperitoneum, allows adequate ventilation without pharyngeal damage being caused by the LMA. Passage of an intragastric tube sump suction device through the LMA SupremeTM to empty the stomach is an integral part of their technique. This maneuver should reduce the risk of regurgitation and aspiration of gastric contents. They showed significant reductions in pharyngolaryngeal morbidity in their experimental group when compared to a control group where intracuff pressure was set at 60 cm H2O pressure, the maximal pressure allowed by the manufacturer’s recommendation. They conclude that adequate sealing can be provided at lower cuff volumes and intracuff pressures than this level of 60. Their conclusions only apply to their defined population of relatively healthy, non-obese individuals with no airway difficulty, and cannot be extended to questions of safety or efficacy for LMA use in complex or high risk situations [2]. Using manometry to monitor cuff pressure is not a new idea, but neither is it a common practice in many areas of the world. Pharyngolaryngeal morbidity caused by overdistension of these cuffs has provided rates for sore throat and dysphagia as high as 50%, with some instances of much more significant complications being engendered [3]. Archie Brain, the original inventor of the LMA, and his co authors wrote of this in an editorial in 2014 [3]. A survey which they had conducted found that “anaesthetists in the UK are not routinely checking ... cuff pressures.” Many practitioners rely on their own clinical sense of the adequacy of cuff inflation and are not adequately following up with their patients to assess the morbidity they are causing. Brain and his colleagues propound and debunk five common myths, to which the study by Wang and colleagues [1] adds. These are: