Laryngeal mask airway, so many limitations?

We read with great interest the article published by Rossi et al., entitled “Safety aspects of desflurane anesthesia and laryngeal mask airway.”1 We would like to comment on the patient-related factors limiting laryngeal mask airway (LMA) usage. LMA is usually used in children under 15 years of age and is proven to be safe and effective. Actually, there is a growing interest in its use in association with desflurane. Despite desflurane is less commonly used in this range of population, recent studies reported a relative safe use of this halogenated also in children whose airways were supported with laryngeal mask. For example, Lerman et al. report a frequency of airway events with desflurane similar to those with isoflurane after LMA removal with an awake patient.2 Furthermore, the difference in events removing LMA in awake patients or deep anesthesia is similar in desflurane and sevoflurane use.3 Lastly, in our experience, the safe LMA profile together with desflurane pharmacokinetic, permits to perform anesthesia in young patients undergoing orthopedic surgery also in association with loco-regional analgesia. Second-generation supraglottic airway devices have contributed to the increase in LMA use, therefore these show that obesity is not a factor limiting its use. A Cochrane Review published in 2013 reported a failure positioning LMA rate of 3% to 5% in obese patients but also a good oxygenation with this device.4 According to 2011 NAP4, the limitation regarding LMA use in obese patients includes patients whose surgery was performed in the lithotomy position and/or head down position.5 In addition, in a group of “cervical disorder” like neck flexing difficulty, we suppose that, with caution and surgery related possibilities, LMA can prevent difficulties during intubation and also results as ventilation device bridging to the orotracheal intubation when it is mandatory. In conclusion, we want to congratulate the authors for a clear and well written paper. However, in our opinion, LMA could provide more possibilities. G