Indian Journal of Anaesthesia

: 2019  |  Volume : 63  |  Issue : 1  |  Page : 76--77

Are we misusing the ILMA tube? A cause of concern?

Anju Romina Bhalotra 
 Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College, New Delhi, India

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Dr. Anju Romina Bhalotra
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How to cite this article:
Bhalotra AR. Are we misusing the ILMA tube? A cause of concern?.Indian J Anaesth 2019;63:76-77

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Bhalotra AR. Are we misusing the ILMA tube? A cause of concern?. Indian J Anaesth [serial online] 2019 [cited 2021 Jul 29 ];63:76-77
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Fibreoptic intubation is still considered the gold standard technique for intubation of a patient with a difficult airway. Many patients with a truly difficult airway have extensive head and neck malignancies and require major reconstructive surgical procedures.

Many different types of endotracheal tubes have been used for fibreoptic-guided intubation. The intubating laryngeal mask airway (ILMA) tube was originally designed to be used with ILMA. There are numerous reports in literature to suggest that this tube is superior to other tubes for facilitating fibreoptic intubation. The bevel of this tube is made of silicone and hence is softer than a conventional polyvinyl chloride (PVC) tube. In addition, the bevel is blunt and hemispherical. The tube has an additional advantage of having the leading edge in the midline and is softer and more flexible than a PVC tube. The insertion of this tube over a fibrescope is easier and gentler than other tubes.[1],[2] According to Greer et al. and other authors, fibreoptic intubation can often be difficult with repeated attempts at passing a tube through the glottis leading to laryngeal trauma and they proposed that the use of an ILMA tube may offer a distinct advantage during fibreoptic intubation.[1],[2]

Taking cognizance of the literature, many anaesthesiologists have adopted the routine use of ILMA tube for fibreoptic-guided intubation. No doubt it makes the procedure smoother and probably a little less traumatic, but it is worthwhile remembering that a silicone ILMA tube costs about 100 times more than the cost of a PVC tube, it is reusable hence requiring sterilisation before use and, perhaps more importantly, it has a cuff with the characteristics of a high pressure cuff. In patients undergoing surgery for head and neck cancers, the duration of surgery is often very prolonged and many patients are shifted to the intensive care unit for elective postoperative ventilation for 24–48 h. Under these circumstances, the use of an ILMA tube is undesirable. No doubt minimising trauma and the need for repeated attempts at tube passage through the glottis is of paramount importance during fibreoptic intubation, but this can be achieved by simpler (and cheaper) means. We are routinely warming a PVC endotracheal tube by immersing the tube in a bottle of warm to hot saline prior to mounting it on the Fibreoptic bronchoscope. The technical staff have been trained to do so and this renders the tube extremely soft and gentle and limp so that it hugs the fibrescope and gently and effortlessly negotiates the glottic opening. The only circumstance in which I feel it is a reasonable option to resort to the use of an ILMA tube is when the patient has a fixed flexion deformity of the neck where a PVC tube with its sharper bevel may cause trauma to the posterior pharyngeal wall and the blunt IMLA tube offers a distinct advantage. In other situations, a PVC tube may be used with suitable preparation as its low-pressure cuff offers greater patient safety in patients undergoing prolonged surgery and perhaps requiring postoperative ventilation. There are a wide variety of equipments available to the anaesthesiologist these days and it is up to us to make judicious and safe choices.

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1Greer JR, Smith SP, Strang T. A comparison of tracheal tube tip designs on the passage of an endotracheal tube during oral fiberoptic intubation. Anesthesiology 2001;94:729-31.
2Erickson KM, Keegan MT, Kamath GS, Harrison BA. The use of the intubating laryngeal mask endotracheal tube with intubating devices. Anesth Analg 2002;95:249-50.