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Optimization of Supraglottic Airway Placement

Everything You Need To Know

Infographic detailing optimization essentials for supraglottic airway placement, including techniques for manipulation, size selection, suction and oxygen use, adjuncts, and sedation.
EssentialsManipulationsAdjuncts
Size & TypeSuction & Oxygen FlowMuscle Tone

The Essentials

Just like with FMV, SGA placement and effectiveness can be improved with a structured optimization framework recommended in The Vortex Approach. Unlike the FMV, where the difficulty usually arises from inadequate seal or obstructing upper airway anatomy, SGA failure is typically related to one of these three factors:

Entry:
Inability to place the supraglottic airway into the mouth (e.g., limited opening or muscle rigidity).

Passage:
Difficulty advancing the device through the pharynx to the larynx.

Seating:
Improper alignment or poor cuff seal causing obstruction, leak, or inadequate ventilation.

SGA optimization should focus on overcoming these three obstacles.

Flowchart detailing best efforts for managing supraglottic airway, including categories, interventions, and their impacts.

Click here to open a full-sized image in a new tab.

Blue hand icon within a circular outline.

MANIPULATIONS

All fundamental maneuvers described under FMV optimization hold true, including the head-tilt, chin-lift, and jaw thrust. However, with SGA placement, we introduce another important concept: patient positioning for intubation (applies to both, SGA and ETT placement).

The specific manipulation we are referring to here is flextension, also known as ramp positioning, or “BUHE” (bed up, head elevated).This technique involves elevating the patient’s head and shoulders so that the ear is on the same horizontal plane as the sternal notch.

Illustration showing head and neck manipulations, including flexion, extension, jaw thrust, and cricoid pressure techniques.

Remember!

A cartoonish representation of a set of dentures held in a gloved hand, underwater with bubbles and aquatic plants in the background. Labels indicate 'BVM = IN', 'SGA = OUT', and 'ETT = OUT'.
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ADJUNCTS

There are three adjuncts we can use to ease the passage of an SGA.

  1. A Tongue Depressor can be used to displace the tongue and mandible for optimal insertion.

2. A Direct Laryngoscope blade can be used in the same manner, with even more powerful displacement of anterior airway structures.

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2. A Gum-Elastic Bougie can be used as well, however, it’s a lesser known trick and can only be used with specific devices. A bougie is deliberately placed into the esophagus, and then fed into the gastric channel of a compatible supraglottic airway device. The rationale is that the bougie guides the tip of the SGA device precisely into the esophagus and optimizes laryngeal alignment.

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SIZE & TYPE OF DEVICE

Because they are designed for emergencies, most SGA devices are pragmatically sized and color coded for rapid selection.

Troubleshooting Size & Seal:

Leak + high pressures → reduce pressure or size up

Leak + max cuff volume → deflate/reseat, then size up

Gastric sounds → pull back, reduce pressure, reseat/resize

Resistance/poor compliance → withdraw slightly, reseat, check obstruction

Sometimes, the device was properly placed, but it doesn’t sit well. One way this can be immediately fixed is to deflate the cuff, twist the device a bit to realign it with the airway axis, and re-inflate.

Illustration showing the process of inflating a cuff with arrows indicating twisting motion and the word 'TWIST CUFF INFLATION' in bold, colorful text.
Table of Laryngeal Mask Airway (LMA) sizes, patient weight ranges, maximum cuff volumes, and maximum orogastric tube sizes.
A set of eight medical laryngoscope blades of varying sizes, featuring a curved design with green tips and clear handles.
A chart detailing the sizes, colors, patient criteria, and maximum cuff volumes for King Airways, ranging from size 0 to 5 with corresponding specifications.
A set of various medical airway management devices, including clear plastic tubes with colored connectors, arranged in a line from smallest to largest.
A set of i-gel supraglottic airway devices in various sizes, including pink, blue, white, and green colors, lined up in order from smallest to largest.
Icon depicting arrows indicating different directions within a circular border.

SUCTION & O2 FLOW

We will repeat this every time, until it sticks!

YOU SHALL NEVER MANAGE AN AIRWAY WITHOUT OXYGEN OR WITHOUT SUCTION.

Oxygen flow meter with a vertical glass tube marked with measurements, a green handle labeled for attachment to the wall, and direction arrows indicating attachment and adjustment instructions.

Suction

While suction remains a core initial step of decontamination, it’s use in supraglottic airway placement goes even further!

Watch this trick demonstrated by Dr. Jim DuCanto – the inventor of the SALAD technique and a core faculty member of PAC.

Circular graphic featuring a symmetrical design with vertical and horizontal lines, resembling a stylized tree or network.

MUSCLE TONE

As the final category of optimization strategies recommended by the Vortex Approach, “Muscle Tone” is consistent and relevant across all three lifelines, not just FMV.

It refers to pharmacologic sedation & paralysis, used in general anesthesia and rapid sequence induction.

While the process of RSI and the pharmacology of sedatives and paralytics are beyond the scope of this installation, the bottom line is this: the more awake, tense, and agitated your patient is, the more difficult it will be to ventilate them.

Sedation reduces protective reflexes and neuromuscular blockade (paralysis) eliminates active airway resistance and muscle opposition. Jaw tension resolves, vocal cords relax, and chest wall compliance improves. With no competing spontaneous effort, positive pressure ventilation becomes more controlled and efficient. The goal is to work for the patient, not against them.

A collection of various medication vials, including Fentanyl Citrate, Rocuronium, Succinylcholine Chloride, Ketamine HCl, Levophed, and Etomidate, used for medical injections.

If you want to dive deeper into the process of RSI and airway pharmacology, you can visit our dedicated learning spaces by clicking the buttons below and purchasing full access to our content.

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Banner for a learning space focused on airway pharmacology, featuring a lung icon and the title 'AIRWAY PHARMACOLOGY' prominently displayed.

Congratulations!

You completed the Supraglottic Airway section.

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