Journal of Anaesthesiology Clinical Pharmacology

: 2014  |  Volume : 30  |  Issue : 4  |  Page : 587--588

LMA Proseal for the surgical procedures in prone positioning - Few comments.

Shafiq Faraz, Muhammad Ul Haq Irfan, Fazal Hameed Khan 
 Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan

Correspondence Address:
Fazal Hameed Khan
Department of Anaesthesiology, Aga Khan University, Karachi

How to cite this article:
Faraz S, Irfan MU, Khan FH. LMA Proseal for the surgical procedures in prone positioning - Few comments. .J Anaesthesiol Clin Pharmacol 2014;30:587-588

How to cite this URL:
Faraz S, Irfan MU, Khan FH. LMA Proseal for the surgical procedures in prone positioning - Few comments. . J Anaesthesiol Clin Pharmacol [serial online] 2014 [cited 2021 Apr 21 ];30:587-588
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Full Text


We read the article by Sharma et al.[1] about the use of proseal LMA in the prone position with great interest. We felt the necessity to highlight a few points related to this article for clarification and better understanding.

The authors provided the rationale of using Proseal LMA - that any airway device including the endotracheal tube (ETT) may be dislodged in the prone position. However, we disagree with this fact as, after years of experience, we have not encountered any case of inadvertent extubation of the ETT in the prone position. Adequate planning, vigilant supervision and securing the ETT properly are the key to the success for the prevention of accidental extubation in this position. The reference numbers (2) and (3) mentioned in this context are different scenarios, where the patients were pediatric and neonate. In both these case reports, the LMA insertion was used as a rescue measure. Therefore, the results would not be a reflection of the scenario related to adult patients.

The authors provided reference (16) from the fourth national audit project (NAP) of the Royal College of Anaesthetists UK, which showed that the supraglottic airway devices (SADs) were the preferred choice for general anesthetics among the British anesthetists. The conclusion does not reflect the use of LMA for the surgical procedure in prone positioning. It is also very important to note that the result of the same audit implies that the inappropriate use of SADs was associated with airway-related events, [2] which we have to consider as the standard position for LMA insertion is the supine sniffing position. [3] Any alteration from this standard may be associated with airway-related events as mentioned in the NAP audit.

The patient position as mentioned in Figure 2 of the article does not meet the standards of prone positioning. [4] The overhead abduction of the arms more than 90 degree is very obvious in the image, and the same happened to the pressure points at the ulnar nerve level. There is no provision to free the abdominal compression. There are no side arm boards and no gel pads under the hands, which may have been done to save time for the study purpose. There is a possibility that if all precautions would have been taken by the authors to make a safe position, then the inference of the study may have been different.

The authors calculated the surgical readiness time from induction in both groups. In the P group, it was started after making the position while in the S group, it was started at the beginning of anesthesia induction. This creates uncertainty as far as the authenticity of the results is concerned as some time must have been spent making the prone position in the P group before start of induction, which is not captured in the analysis of results.


1Sharma B, Sood J, Sehgal R, Sahai C, Gera A. ProSeal laryngeal mask airway TM insertion in the prone position: Optimal utilization of operation theatre personnel and time? J Anaesthesiol Clin Pharmacol 2014;30:177-82.
2Woodall NM, Cook TM. Executive summary. 4 th National Audit Project (NAP4): Major complications of airway management in the United Kingdom. Report and Findings. The Royal College of Anaesthetists London. 2011.
3LMA Proseal. Instruction Manual. Available from:[Last accessed on May 25 th 2014.
4Knight DJW, Mahajan RP. Patient positioning in anaesthesia. Continuing Education in Anaesthesia. Crit Care & Pain 2004;4:5.