Laryngeal mask airway, so many limitations?

We read with great interest the article published by\r\nRossi et al., entitled “Safety aspects of desflurane anesthesia\r\nand laryngeal mask airway.”1 We would like to\r\ncomment on the patient-related factors limiting laryngeal\r\nmask airway (LMA) usage.\r\nLMA is usually used in children under 15 years of\r\nage and is proven to be safe and effective. Actually,\r\nthere is a growing interest in its use in association with\r\ndesflurane.\r\nDespite desflurane is less commonly used in this\r\nrange of population, recent studies reported a relative\r\nsafe use of this halogenated also in children whose airways\r\nwere supported with laryngeal mask. For example,\r\nLerman et al. report a frequency of airway events\r\nwith desflurane similar to those with isoflurane after\r\nLMA removal with an awake patient.2 Furthermore, the\r\ndifference in events removing LMA in awake patients\r\nor deep anesthesia is similar in desflurane and sevoflurane\r\nuse.3\r\nLastly, in our experience, the safe LMA profile together\r\nwith desflurane pharmacokinetic, permits to\r\nperform anesthesia in young patients undergoing orthopedic\r\nsurgery also in association with loco-regional analgesia.\r\nSecond-generation supraglottic airway devices\r\nhave contributed to the increase in LMA use, therefore\r\nthese show that obesity is not a factor limiting its use. A\r\nCochrane Review published in 2013 reported a failure\r\npositioning LMA rate of 3% to 5% in obese patients\r\nbut also a good oxygenation with this device.4 According\r\nto 2011 NAP4, the limitation regarding LMA use\r\nin obese patients includes patients whose surgery was\r\nperformed in the lithotomy position and/or head down\r\nposition.5 In addition, in a group of “cervical disorder”\r\nlike neck flexing difficulty, we suppose that, with caution\r\nand surgery related possibilities, LMA can prevent\r\ndifficulties during intubation and also results as ventilation\r\ndevice bridging to the orotracheal intubation when\r\nit is mandatory.\r\nIn conclusion, we want to congratulate the authors\r\nfor a clear and well written paper. However, in our opinion,\r\nLMA could provide more possibilities.\r\nG