In adult or pediatric patients?

In adult cases

I generally use LMA semiinflated during insertion

In adults, despite the guidelines highlighting awake extubation, I use deep extubation and fully-deflated. However, in pediatrics I extubate LMAs while inflated.

Semi-inflated. Completely deflated easily folds. Fully enflated can be more difficult to insert. So I use semi-inflated, usually just as they come from the factory.

I used to insert semi-inflated till I decided to do what the original inventor has recommended, totally deflated and index finger right on top of the cuff, slide it while pushing it backward/ upward. It doesn't fold and I noticed it wont push the tongue back ( this happens a lot with cuff semi inflated and we have to adjust it by pulling it back and pushing it in again)

While insertion, I use semi-inflated in both adults and pediatrics. In order to deflate the cuff completely so that it would not fold it needs a special "Cuff-deflator" that we do not have it in our centers. Do you have this device and use it routinely?

No, we have it but no one uses it, we just deflate the cuff with 20ml syringe and use the plastic part that holds the LMA to get a uniform deflation.

Thank you, do you think removing it semi-inflated (the way it has been during the procedure) will remove the accumulated saliva off the vocal cords and as a result will decrease risk of laryngospasm? I always remove it deep with inflated cuff if there is no contraindication for it.. usually put a blue towel on patient's chest to catch the saliva that come off with it not to mess up everywhere.

Dear Anthony and Shahriar, I have never been comfortable with awake extubation both in ETT and LMA. In elective NPO patients, I extubate the LMA when the patient is deep and fully reversed, if any NDMR has been used, despite the recommendations that it should be performed in awake status. what is your experience in this regard?

i use semi inflated and almost always remove LMA when patient is still deep. when placement of LMA is difficult I introduce it at 180 degree and than rotate the LMA to make it sit in position. Lateral insertion also works well for me

After choosing the correct size, completely deflate the cuff while pushing it posteriorly so that it assumes a smooth wedge shape without any wrinkles.

(ROBERTS & HEDGES' Clinical Procedure in Emergency Medicine (2014), Basic Airway Management and Decision Making, Pages 53 and 55)

I prefer to completely deflate both LMA and ILMA cuffs before insertion and never used them in awake patients. Because ...

Limited mouth opening (

I used to prefer it semi-inflated. But sometimes especially in children when the mouth volume is small , I prefer completely deflated.

The rotational method (180 degrees) which colleagues mentioned, is mostly used in pediatric patients rather than adults. It is extremely cool to handle in children but in adults it is really difficult to use this method due to the larger LMA size used and also due to their tongues being bulkier than pediatric patients.

Regarding the awake patients, LMA has been safely used in awake patients provided that proper local anesthesia/nerve block is performed. It is funny, you can find some movies on the Internet showing some professors performing awake LMA insertion on themselves while teaching their residents!

A presión atmosférica, semi inflada

For classic approach insertion, it is better to inflate partially because the tip of cuff better mouted on esophageal enterance & also the cuff is less likely to bend or fold.

With alternative approach (180" rotation, or Oral airway approach) I deflate it completely, this allow to rotate the cuff in pharynx easier with less risk for traumatizatio.`

One of the main problems extraglottic inserting a device is fold or drag the epiglottis. In this regard, the forward area of the dipositive should be as thin as possible. This will improve the correct insertion. In other words, completely deflated.

In our VA hospital, where I work in the ORs, we we had the iGel LMA since 2007.  This does not require inflation and is therefore easier to use.  After 10-20 seconds it has molded to the airway and once we place the gastric tube we are able to even use these for pressure support ventilation. 

I prefer semi-inflated cuff. And I would never inflate it without testing ventilation, sometimes the patient would be ventilated better with semi inflated tube.

Semi-inflated.

Also a significant percentage of patients for whom an iGel will not seal adequately or the iGel causes base of tongue pressure and venous engorgement will be better with the "classic" LMA.

I always check for airway patency and minimal leakage of airway gases.....I still find it fascinating that some will happily ventialte patients for laparoscopic and other procedures,head down etc etc on an LMA,and trust that airway soiling may not be an issue.....anyhow,that's maybe a different question.

with increasing experts one can use fully inflated with selection of proper size , recomended volume and suitable lubrication to minimize trauma or any complication

Semi-inflated

I insert fully deflated cuff.