Common Indications

A supraglottic airway device is used when you need a more reliable method of oxygenation than face-mask ventilation, but you don’t require (or cannot achieve) endotracheal intubation.

• Primary airway in elective anesthesia
• Rescue airway during difficult mask ventilation
• Rescue after failed intubation
• Bridge to a definitive airway
• In cardiac arrest patients

Contraindications

Remember! A supraglottic airway CANNOT be used in an awake patient with an intact gag reflex!

Absolute

• Inability to open the mouth sufficiently
• Complete upper airway obstruction at or below the glottis

Relative

• High aspiration risk (full stomach, active vomiting, severe GERD)
• Severe obesity with high airway pressures anticipated
• Known or suspected supraglottic pathology
• Severe pulmonary pathology requiring high peak inspiratory pressures

The Essentials

1️⃣ Difficult airway was uncommon — but real

• Among 658,104 general anaesthetics, difficult airway management occurred in 0.74% of cases.
• Most were triggered by:
  • ≥ 3 intubation attempts (75%)
  • Failed intubation (5%)
  • Isolated difficult mask ventilation (20%)

Even in high-volume systems, true difficulty is rare — but when it happens, decisions matter.

2️⃣ Supraglottic airways were used less than guidelines suggest

• SADs were attempted in only 12.4% of difficult airway cases.
• This is striking given their prominent role in major difficult airway guidelines (e.g., DAS, Vortex).

Bottom line: SADs may be underutilized in real-world difficult airway management.

3️⃣ When used, success was moderate — not perfect

• Overall success rate of SAD in difficult airway cases: 65%
• In “cannot intubate, cannot facemask ventilate” situations:
  • Used in 19% of cases
  • Success rate: 63%

This is important. In real-world practice across all clinician experience levels, SAD success was not the >90% often quoted from smaller or specialist studies.

4️⃣ SAD was rarely attempted before surgical airway

• In the 22 cases that progressed to emergency front-of-neck airway:
  • SAD was attempted in only one case

That finding raises critical questions about:

• Escalation behavior
• Guideline adherence
• Cognitive overload in crisis
• Whether a “best effort at all lifelines” approach is consistently applied

5️⃣ Prediction of difficulty was limited

• Only a small proportion of difficult airways were predicted pre-operatively.
• Even when both mask ventilation and intubation were anticipated to be difficult, SAD was infrequently planned as the primary device.

Planning and anticipation did not consistently translate into early SAD use.

6️⃣ Real-world data matters

This study represents:

• 75% of Danish anaesthesia departments
• All levels of clinician experience
• Everyday clinical practice, not simulation or expert airway teams

It reflects what actually happens — not what we think should happen.

Big Picture Implications

• SADs are foundational in difficult airway algorithms.
• Yet in practice, they are not frequently attempted.
• When used, they are moderately successful, not universally rescuing.
• There may be a gap between guideline design and human behavior under pressure.

This reinforces the importance of:

• Training for optimized SAD placement
• Explicit “best effort” attempts
• Cognitive tools that reduce hesitation and bias
• System-level reinforcement of structured escalation strategies

If you’d like, I can also:

• Convert this into a PAC-style infographic summary
• Frame it through the Vortex lens
• Or write a short interpretive commentary tying it to modern airway cognitive tools and human factors

“Stability in Seconds.”

The Essentials

Now that you’re familiar with the most common types of SGAs, let’s actually learn how to use them! We will go over how to insert each device momentarily, but first, it’s worth mentioning a few common principles.

Universal Technique

The beginning is the same, regardless of the device.

1. Pick the correct size.
2. Deflate the cuff (if present).
3. Apply lubrication to the posterior (dorsal) side of the device.
4. Position the patient (head-tilt, chin-lift) and scissor the mouth open.

Universal Insertion Biomechanics:

• Insert with the tip riding the hard palate → soft palate → hypopharynx.
• Keep the device midline and rotate only if your device’s technique calls for it
• Advance until you feel definitive resistance or the depth marker is at the incisors (device-dependent)

Device Specific Techniques

Head to the specific devices below for device specific techniques.

After Placement

Everything You Need To Know

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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.

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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.

Remember!

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.

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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.

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.

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SUCTION & O₂ FLOW

We will repeat this every time, until it sticks!

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

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.

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.

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.

Placement Technique

Preparation

1. Position the patient (sniffing or neutral depending on context).
2. Preoxygenate if possible.
3. Check cuff integrity Deflate the cuff fully into a smooth, flat shape.
4. Lubricate the posterior surface only (avoid excess lubricant at the tip).
5. Ensure suction is available.

Device Insertion

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This has several benefits:

1. Controls force & direction of insertion.
2. Allows you to use your index finger to push the tongue if it gets in your way.

Insertion (Inflatable LMA, Classic Technique)

1. Open the mouth using a scissor technique.
2. Insert the device along the hard palate, advancing posteriorly with the curve following the palatopharyngeal contour.
3. Advance until resistance is felt (mask seated at the hypopharynx).
4. Inflate the cuff with the recommended volume (do not exceed manufacturer limits).
5. Connect to ventilation device.

Avoid force. If resistance occurs early, withdraw slightly and re-advance while maintaining midline positioning.

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Insertion Technique Reviews

Watch this rapid review and longer instructional video. Once you’re ready, head to the hands-on station to practice LMA insertion.

Background: The 1st Supraglottic

The laryngeal mask airway (LMA) was the first supraglottic device. It was discovered by Dr. Archibald Brain in 1981 as an alternative to FMV & ETT.

It is designed to sit over the laryngeal inlet and provide a hands-free conduit for oxygenation and ventilation without passing through the vocal cords. It occupies the middle ground between face-mask ventilation, basic airway adjuncts (OPA/NPA) and endotracheal intubation.

It is widely used in anesthesia, emergency airway management, and resuscitation as both a primary airway device and a rescue option when face mask ventilation or intubation is unsuccessful.

Here is a quick overview from ABCs of Anesthesia:

Description

The LMA Classic consists of:

• Airway tube: Connects to a bag-valve device or ventilator.
• Elliptical mask/cuff: Inflatable (in many models) and designed to seat over the glottic opening.
• Pilot balloon (inflatable types): Indicates cuff inflation status.
• 15 mm connector: Standard airway circuit connection.

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Modern generations of the LMA vary significantly and may include:

• Second-generation designs with gastric drainage channels
• Improved seal pressures
• Preformed or anatomically curved shafts
• Disposable and reusable options
• Wide, patent ventilation channels without bars to allow for inline ETT delivery,

Because performance characteristics vary, clinicians should be familiar with the specific device used in their institution.

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Second-generation LMAs with gastric access improve aspiration risk mitigation but do not eliminate it. Clinical judgment is essential.

Sizing

LMA size selection is generally based on patient weight (check manufacturer guidance). Typical adult ranges:

Using too small a device results in poor seal and leak. Too large increases trauma risk and insertion difficulty.

Always confirm the specific sizing table for the device you are using.

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