Archie Brain: celebrating 30 years of development in laryngeal mask airways

Anaesthesia 2012; 67: 1375-1385.

T.C.R.V. van Zundert, J.R. Brimacombe, D.Z. Ferson, D.R. Bacon and D.J. Wilkinson

Summary

The practice of anaesthesia was revolutionised by the ideas of Archie Brain. The routine use of a facemask to manage the airway was not a hands-free technique, despite the development of various harnesses, and made adequate record-keeping difficult. The tracheal tube was frequently associated with morbidity, which some felt was unsuitable for day surgery. Brain developed an airway management device that was less stressful to the patient than tracheal intubation, yet was, however, as safe as using a facemask and airway. Brain also hoped his device would function for cases where mask ventilation was particularly difficult and thus give anaesthetists a safer alternative to a complex intubation, especially in emergency scenarios.

Above: Dr Archie Brain

Before the invention of the Laryngeal Mask Airway® (LMA) by Brain in 1981, the airway was maintained by tracheal intubation or facemask +/- oropharyngeal airway. The 30 years in the review title covers the period from the publication of his first clinical trial until the introduction of the LMA® Supreme™, and describes his drive to develop the LMA from the initial concept to a clinically usable device, and then to multiple diverse products with specific functions besides providing a patent airway. He sometimes tested more than one prototype (some of which are pictured in the article) in a day, and the time required to manufacture these resulted in the failure to publish significant amounts of his work.

The article notes that “(ethics) approval in those days carried no constraint with regard to the number of patients studied…. the practice took several years. It would be difficult to do this today”, and so the early clinical trials were open-ended as different prototypes were assessed. However, this exhaustive process meant that, when factory manufacturing in a range of sizes commenced in 1987, the device was fully functional [1] and its use spread rapidly in the UK over just a few years.

Besides its use as a primary airway device, the potential of the LMA for rescue after failed intubation shortly became apparent, especially in obstetric cases. This led to the Intubating LMA (now LMA® Fastrach™), which again could be used both electively or as a rescue device, but with much improved success rates for tracheal intubation. Continued development led to the LMA® Supreme™, combining features of the Intubating LMA with increased airway seal pressure and an oesophageal venting lumen, and research continues to this day [2]. Since this review by van Zundert, even more variants have emerged.

For the majority of UK anaesthetists, the pre-LMA days are ancient history, and the LMA (or other supraglottic airway devices) are preferred so comprehensively that the skills of tracheal intubation and facemask-holding are considered to be inadequately acquired. A massive change brought about by one man!

Dr Katy Miller
Co-opted member of the Trainee Committee, Association of Anaesthetists
Consultant Paediatric Anaesthetist, Birmingham Children’s Hospital

References 

1. Alexander CA, Leach AB, Thompson AB, Lister JB. Use your Brain! Anaesthesia 1988; 43: 893-4. 
2. DI Filippo A, Adembri C, Paparella L, et al. Risk factors for difficult Laryngeal Mask Airway LMA-Supreme™ (LMAS) placement in adults: a multicentric prospective observational study in an Italian population. Minerva Anestesiologica 2021; DOI: 10.23736/S0375- 9393.20.15001-6.

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