PROS AND CONS Some say wait until the patient's reflexes have returned to remove the LMA. Others say don't wait, extubate: Patients will be ready to move sooner.

Anesthesia providers love laryngeal mask airways (LMAs), but they can disagree about the best time to remove supraglottic airway devices from patients. There are two camps: those who think patients should still be "deep" during removal and those who think they should be fully awake. Nearly two-thirds (63%) of the 305 readers Outpatient Surgery polled last month remove LMAs before the patient emerges. Let's talk about the advantages and disadvantages of both approaches.

Removing LMAs in awake patients
Those who prefer to remove the LMA after the patient's awake believe there should be minimal manipulation of the LMA until the patient's reflexes have returned and the patient can open his mouth on command. But there are several factors to keep in mind regarding this approach.

On the plus side, if you wait until patients can respond to commands, they'll be awake enough to cough up secretions that may be left behind after the LMA is removed. There may also be less risk of laryngospasm if all reflexes are intact. Plus, patients can be successfully suctioned, if necessary, with no worries about depth of anesthesia, and the negative effects that suctioning may have.

But what if intubated patients start coughing, and don't respond to commands? Should you leave the LMA in until the coughing stops? Secondly, you'll need to take precautions when inserting the LMA, to prevent the patient from biting the main tubing and preventing the passage of air. The LMA can't be removed if teeth are tightly clenched. Inserting a small bite block beside the LMA, in case patients clamp down before they can respond to commands, allows sufficient passage of air, and lets you remove the LMA without damaging it or the patient's teeth.

Some feel that leaving the LMA in place until the patient is fully awake can actually stimulate coughing and give patients the feeling that they can't breathe. That may send them into panic mode if they're still lightly anesthetized. Patients who still have breathing devices in place may also feel that they're waking up before procedures are finished.

Should you remove LMAs before or after the patient wakes up?

• before63%
• after37%

SOURCE: Outpatient Surgery MagazineInstaPoll, February 2016, n=305

Removing LMAs in "deep" patients
Proponents of "deep" extubation say their patients are ready to move sooner. The LMA is out by the time the surgery is complete, so there's no need to keep patients anesthetized deeply. Also, with deep extubation, patients usually don't cough; and coughing can strain the fresh suture line.

But there are also several important considerations if you're considering an extubation while the patient is still anesthetized. It's important that patients be breathing spontaneously and without interruption when LMAs are removed. This makes the transition to a mask more effective.

Was the LMA insertion smooth? Smooth insertion usually ensures easy removal when patients are anesthetized. Lower Mallampati scores (1 or 2) can help you feel confident that there's no obstruction. A tight seal with no leaks indicates that the LMA is properly seated and won't irritate surrounding tissue during removal.

There's no concrete figure, but a high BMI may be the strongest argument against extubating a deep patient. It's best to assess the airway, the patient's breathing, and the need to maintain positive pressure ventilation in these patients if there is significant tissue pressure on the chest and abdomen at the end of the procedure. High-BMI patients may be borderline when you're deciding between endotracheal and LMA airway maintenance. You may also need to consider whether patients have GERD or gastroparesis, since they can compromise airway management.

When the surgeon is closing, or the procedure is nearing the end, deflate the LMA (no adjustment to inhalation agent is made at this point), and remove it. Leaving the inhalation agent on ensures that if patients are deep enough to tolerate the LMA, they'll be deep enough to tolerate removal. After the LMA is removed, apply the facemask to the breathing circuit and control ventilation with the facemask. You can then titrate the anesthetic down, based on when the surgeon expects to finish and when the patient will be ready to be transported. Usually, patients will awaken as if the entire procedure was performed under mask ventilation. There's complete airway control, little coughing and no question as to whether they're ready for transport, because they're as conscious as patients who were extubated awake.

Before or after?
So, should you remove LMAs before or after the patient wakes up? That decision should always be based on patient safety and the provider's comfort level. OSM