LMA-assisted Fiberoptic Tracheal Intubation or
The LMA-Fiberoptic Intubation
The LMA-Fiberoptic Intubation
  1. Arguably the easiest fiberoptic intubation technic to perform
      Usually less than 5 cm to navigate fiberscope from LMA to glottis
      Ideal for the relatively inexperienced operator
  2. LMA generally promptly provides a satisfactory airway and allows oxygenation and ventilation while equipment is assembled (e.g., in the event of unexpected difficult airway)
  3. Facilitates use of inhalational agent sedation/anesthesia
  4. Allows oxygenation and ventilation after each step of the procedure
  1. Cannot be used if mouth opening is impossible (so we still need to practice a fiberoptic nasotracheal technic)
  2. Requires knowledge of and availability of the required materials

Technic of LMA Fiberoptic Intubation Fiberoptic Intubation via LMA
  1. Assemble and check equipment
  2. Optional: administer airway local anesthesia
  3. Induce general anesthesia or sedation
  4. Insert and secure appropriate LMA, oxygenate, ventilate, and optionally administer inhalational agent
  5. Confirm that appropriate ETT of adequate length is mounted on fiberscope
  6. Pass fiberscope through LMA "guide," under epiglottis, until clear view of glottis is obtained
  7. Optionally administer 2% lidocaine onto larynx through scope, IV anesthetic agent(s), or muscle relaxant
  8. Advance fiberscope well into trachea (e.g., to carina or a main stem bronchus)
  9. Hold fiberscope fixed and advance ETT along fiberscope, through LMA and into treachea (may have to slightly withdraw ETT, rotate it 90 degrees and re-advance one or more times to move tip past glottis)
  10. Hold ETT and LMA fixed and withdraw fiberscope (visualize ETT in trachea)
  11. Oxygenate, ventilate through ETT (confirm ETCO2 and breath sounds)
  12. Optionally inflate cuff of cuffed tube
  13. Secure ETT and LMA for duration of procedure
  14. At end of procedure ETT and LMA may be removed together or ETT may be removed earlier, allowing completion of case and/or emergence using the LMA
Optional removal of LMA with or without change to larger ETT Indications
  1. Larger (or different) ETT than one used in technic above is needed
  2. Prolonged intubation (e.g. outside the operating room) is planned
  3. Presence of LMA inhibits surgical procedure (e.g. some ENT cases)
  1. Peform technic of LMA fiberoptic intubation as above, perhaps optionally using a smaller size ETT
  2. Insert airway exchange catheter (e.g. Cook) through ETT well into trachea (e.g. a main stem bronchus)
  3. Fix airway exchange catheter and remove LMA and ETT over airway exchange catheter
  4. Fix airway exhange catheter and insert desired ETT over it into trachea (may have to slightly withdraw ETT, rotate it 90 degrees and re-advance one or more times to move tip past glottis)
  5. Hold ETT and remove airway exchange catheter
  6. Oxygenate, ventilate through ETT (confirm ETCO2 and breath sounds)
  7. Optionally inflate cuff
  8. Secure ETT
Alternative for ETT's smaller than smallest airway exchange catheter
  1. Perform LMA fiberoptic intubation as above
  2. Temporarily extend ETT by connecting it to another of the same size using the cut end of the appropriate ETT connector, or by replacing the connector with a smaller size ETT
  3. Hold extended ETT and remove LMA over it
  4. Remove extension to ETT, reinsert connector
  5. Oxygenate, ventilate (re-confirm ETCO2 and breath sounds)
  6. Secure ETT
Johr M, Berger TM. Fiberoptic intubation through the laryngeal mask airway (LMA) as a standardized procedure. Pediatr Anesth 14:614, 2004
Yang YS, Son CS. Laryngeal mask airway guided fiberoptic tracheal intubation in a child with a lingual thyroglossal duct cyst. Paediatr Anaesth 13: 829-831, 2003

Greg Gordon MD