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Airway - Laryngeal mask airway

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The method of insertion is similar for all types of LMA and is applicable across devices

We have based our description around the i-gel (non-cuffed) and the Supreme (cuffed) LMA


Rescue airway device (failed rapid-sequence intubation, difficult bag-mask ventilation)

Cardiac arrest

Facial trauma


Deeply reduced level of consciousness (GCS 3, without gag reflex)

Contraindications (absolute in bold)

Limited mouth opening (<2cm)

High airway pressures


Bag-mask ventilation with oral or nasopharyngeal airway


Informed consent

Medical emergency

Consent is not required

Potential complications

Failure to ventilate (incorrect placement, incorrect size, folding of cuff or epiglottis, distorted anatomy)

Laryngospasm (if airway reflexes intact)

Vomiting (if gag reflex intact)

Airway injury (with bleeding)



Procedural hygiene

Standard precautions

PPE: non-sterile gloves, surgical mask, protective eyewear or shield


Resuscitation bay


Procedural clinician

Airway assistant


LMA (sized by estimated patient weight, if uncertain use the larger LMA initially)

Water-soluble lubricant


Neck flexion with atlanto-occipital extension (sniffing position), or

Neck in neutral position with spinal immobilisation (cervical injury suspected)

Head-tilt chin-lift or jaw thrust applied

In adults the sniffing position is achieved by elevating head approximately 10cm while tilting the head posteriorly. This achieves horizontal alignment of the sternum and external auditory meatus. Small children do not require head lift and infants will require slight elevation of the shoulders due to a relatively large occiput.


Consider sedation and paralysis if not deeply unconscious (GCS 3, without gag reflex)

Sequence (insertion)

Completely deflate cuff (if present), smoothing leading edge

Place lubricant on the posterior and lateral aspects of the LMA

Grasp LMA firmly on the integral bite block

Position the device with cuff facing towards the chin of the patient

Place your other hand on the patient’s occiput to stabilise head during insertion

Press chin inferiorly opening mouth and insert the LMA tip into mouth towards the hard palate

Glide the device downwards and backwards along the hard palate with continuous pressure

Notice a give just before the end point of insertion (passage through the faucial pillars)

Cease pressure when definitive resistance is met (bite block should now rest on the patient’s incisors)

Hold LMA in position and inflate the cuff (if present) with half the maximum volume of the cuff

Tape from maxilla to maxilla and across fixation tab or around the LMA if no tab present

Attach a bag and ventilate assessing chest rise, breath sounds and waveform capnography

Sequence (troubleshooting if poor or noisy ventilation)

Move LMA up and down 2-4cm (to correct folding of LMA cuff or epiglottis)

Reinsert with triple manoeuvre (mouth opening, head extension and jaw thrust)

Reinsert with cuff facing right laterally, applying ‘deep rotation’ 90 degrees anticlockwise into pharynx

Adjust patient (head-tilt chin-lift, jaw thrust, chin to chest, anterior neck pressure)

Insert air into LMA cuff (be aware overfilling may worsen seal)

Change size of LMA (larger if air leak on ventilation, smaller if unable to position correctly)

Consider sedation and paralysis (laryngospasm may occur if not deeply unconscious)

If unresolved, consider bag-mask ventilation, intubation or surgical airway

Post-procedure care

Start continuous waveform capnography and monitoring

Use ongoing bag-mask or pressure-controlled ventilation

Pass a lubricated orogastric tube via the LMA’s gastric drainage tube

Consider sedation and paralysis

Prepare for intubation (seeking senior help if required)

Document after securing definitive airway (completion, complications)


LMA ventilation in facial trauma will reduce aspiration of blood compared to bag-mask ventilation

Sedation and paralysis will usually be required to tolerate an LMA

Current generation LMAs do not require placing fingers in the mouth on insertion


For second generation devices (e.g. LMA Supreme, i-gel) with a reinforced airway tube, digital insertion is no longer required. We recommend primary insertion as described by the LMA manufacturer with a rotational method used if this fails.

The correct terminology for this section should be supraglottic airway devices (SADs) rather than laryngeal mask airways (LMAs). Current devices in emergency department use are not all LMAs. We have used the more common emergency department terminology of LMA.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to


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