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Tips and tricks

Supraglottic airway device insertion using a tongue depressor

Lim, Hyunyoung; Jeong, Mi Ae

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European Journal of Anaesthesiology: February 2020 - Volume 37 - Issue 2 - p 154-155
doi: 10.1097/EJA.0000000000001121
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Supraglottic airway devices (SADs) have been widely used in general anaesthesia or in difficult tracheal intubation states, but sometimes incomplete insertion still occurs.1–4 Therefore, several methods5–9 have been introduced for easy and safe insertion of SADs as well as new devices.10 The authors would like to introduce an easier method to insert SADs using the tongue depressor used for operations in the mouth. The method is as follows. After induction of anaesthesia, press the patient's forehead with the right hand to create neck extension. Then insert the tongue depressor (Fig. 1) along the tongue with the left hand and lift it upward and forward as in laryngoscope insertion. Figure 2 shows a tongue depressor inserted into the patient. Then insert the SAD towards the hard palate with the right hand. At the point where resistance occurs during insertion, remove the tongue depressor while pushing the SAD a little more. It can be inserted smoothly.

Fig. 1:
The tongue depressor used for oral operations.
Fig. 2:
This figure shows a tongue depressor inserted into the patient after pressing the patient's forehead with the right hand to create neck extension.

The tongue depressor has the effect of depressing the tongue and lifting the jaw upward and forward. These effects may have the following benefits.

  • (1) Mouth opening is enlarged and the space for insertion of a SAD into the oral cavity is widened.
  • (2) The tongue depressor prevents the tongue from being pushed down during SAD insertion.

These seem to facilitate insertion of the SAD.

If so, can we consider a laryngoscope or a wooden tongue depressor instead of the tongue depressor in Fig. 1?

A laryngoscope is very familiar to anaesthesiologists and is easy to manipulate. It has the advantages of depressing the tongue and lifting the jaw upward and forward. However, due to the volume of the equipment, especially its thickness, it is difficult to secure space for SADs to enter the oral cavity. If a tongue depressor with a curve like a laryngoscope is developed, SAD insertion will be easier than when using the tongue depressor shown in Fig. 1.

A wooden tongue depressor can be used to push down the tongue, but it is difficult to use it to lift the jaw upward and forward and the depressor can break easily. Therefore, a wooden tongue depressor is not recommended.

When tracheal intubation is performed, hypertension and/or tachycardia are generated due to stimulation of the oropharyngeal structures with the laryngoscope and the larynx and trachea with the endotracheal tube. Similarly, haemodynamic changes may occur when using a tongue depressor because oropharyngeal structures may be stimulated during SAD insertion. However, these changes are likely to be much less severe than the haemodynamic changes that occur as result of a direct laryngoscopy. Video laryngoscopes do not require alignment to achieve optimal visualisation compared with direct laryngoscopes, resulting in less force on the oropharynx11,12 and less haemodynamic changes, such as hypertension or tachycardia.11 Using a tongue depressor may have the same stimulating effects as using a video laryngoscope.

As the number of insertion failures increases, the probability of complications such as airway bleeding, oedema, obstruction and haemodynamic instability is high. Therefore, it is important to do one's best to succeed at the first attempt.

Although the success rate is already high, it can be increased a little more by using this method. Thus, it can be very helpful in securing an airway in anaesthesia and emergency situations.

Acknowledgements relating to this article

Assistance with the letter: none.

Financial support and sponsorship: none.

Conflicts of interest: none.


1. Joly N, Poulin LP, Tanoubi I, et al. Randomized prospective trial comparing two supraglottic airway devices: i-gel™ and LMA-Supreme™ in paralyzed patients. Can J Anaesth 2014; 61:794–800.
2. Wong DT, Ooi A, Singh KP, et al. Comparison of oropharyngeal leak pressure between the Ambu® AuraGain™ and the LMA® Supreme™ supraglottic airways: a randomized-controlled trial. Can J Anaesth 2018; 65:797–805.
3. Lee JS, Kim DH, Choi SH, et al. Prospective, randomized comparison of the i-gel and the self-pressurized air-Q intubating laryngeal airway in elderly anesthetized patients. Anesth Analg 2018; doi: 10.1213/ANE.0000000000003849. [Epub ahead of print].
4. Thomsen JLD, Nørskov AK, Rosenstock CV. Supraglottic airway devices in difficult airway management: a retrospective cohort study of 658,104 general anaesthetics registered in the Danish Anaesthesia Database. Anaesthesia 2019; 74:151–157.
5. Aoyama K, Takenaka I, Sata T, et al. The triple airway maoeuvre for insertion of the laryngeal mask airway in paralyzed patients. Can J Anaesth 1995; 42:110–116.
6. Yun MJ, Hwang JW, Park SH, et al. The 90° rotation technique improves the ease of insertion of the ProSeal™ laryngeal mask airway in children. Can J Anaesth 2011; 58:379–383.
7. Mutch WA. Facilitated insertion of the ProSeal laryngeal mask airway using a lightwand. Can J Anaesth 2006; 53:635–636.
8. Nalini KB, Shivakumar S, Archana S, et al. Comparison of three insertion techniques of ProSeal laryngeal mask airway: a randomized clinical trial. J Anaesthesiol Clin Pharmacol 2016; 32:510–514.
9. Micaglio M, Parotto M, Trevisanuto D, et al. Glidescope/gastric-tube guided technique: a back-up approach for ProSeal LMA insertion. Can J Anaesth 2006; 53:1063–1064.
10. Sorbello M, Petrini F. Supraglottic airway devices: the search for the best insertion technique or the time to change our point of view? Turk J Anaesthesiol Reanim 2017; 45:76–82.
11. Hindman BJ, Santoni BG, Puttlitz CM, et al. Intubation biomechanics: laryngoscope force and cervical spine motion during intubation with Macintosh and Airtraq laryngoscopes. Anesthesiology 2014; 121:260–271.
12. Agrò F, Barzoi G, Montecchia F. Tracheal intubation using a Macintosh laryngoscope or GlideScope in 15 patients with cervical spine immobilization. Br J Anaesth 2003; 90:705–706.
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