So, now I'm a senior SRNA. I'm staff at my site. And so far, things are going OK. I'm actually doing pretty well so far with clinical decision making and, for the most part, I'm really happy with how I'm managing bread and butter cases.

However, the one thing that I'm having trouble with is LMA placement. This is such a basic skill that it's incredibly embarrassing when I struggle with it. I would say about 1/3 of the time I slip the LMA right in, 1/3 of the time I struggle a bit, and 1/3 of the time I have serious issues. It's really killing me

I've tried to fix the problem by experimenting with different techniques, watching videos on the 'net, and asking MDA and CRNAs for tips. But, I'm still not where I want to be. So, anyone have any words of wisdom or tips.

Here's my latest technique (I'm one of those student that is always changing how I do things - which I recognize is not ideal):

2 or versed in preop, 50 of fent when we hit the room, then a pretty good slug of prop (2-2.5mg/kg). I wait for the patient to go apnic and loss of lid reflex, I then usually give a breath or two, then:

-with my left hand I push down on the patient chin/law, opening up the mouth

-with my right hand I grab the lma like a pencil and inset it right in back of the upper teeth, pushing it hard against palate

-I use my right index finger to push the LMA as far in as possible trying to follow the contour of the mouth. I then grab the lma with my left hand and push it/hold it while I take my right hand out of the patient's mouth

The problem
: When I run into trouble it usually happens like this, I advance the LMA along the roof of the mouth and start to get into the oropharynx. Then it feel like I hit a brick wall. With my finger 2/3 of the way into the patient mouth, the LMA wouldn't go any farther. It's literally will not advance.

I'm not sure if I'm hitting tongue or just the back of the oropharynx. Some people have suggested that I either 1.) use my left thumb and forefinger to grab and lift the lower jaw while pushing on the tongue (sorta like how you pick up a fish) or 2.) use a tongue blade to push the tongue toward the base of the mouth. Other people have suggested the problem is not the tongue, but instead results from a failure to extend the neck. These people have suggested that I lift the head with my left hand?

I don't like putting both hands into a patient's mouth, my hands are pretty big and I seem to run out of room. But, I'm open to the tongue blade?

What do you think? What structure in the mouth is causing all my problems?