As we all know there are a number of schools of thought on when to pull an LMAs. My experience in the clinical setting pretty much mirrors what has been covered here in a number of threads.

Pull it deep:

Pro: "Hey John [that's me], think about it, you don't have a secure airway there, it's just like having an oral airway in. Just take it out now [deep] or do you want to wait until they bite down and give themselves negative pressure pulmonary edema?"

Con: "What's the hurry pulling it? It's not like it's stimulating. At that time in the case [emergence] you have a lot going on. Why not keep both hands free as long as possible."

Pull it when they are wide awake

Pro: "Play it safe, let them pull it out themselves. You know they are not in stage II so you don't have to worry about larngospasm."

Con: "It's a dental injury waiting to happen. Plus it will stimulate the patient. Don't you want smooth wakeups, pull it early!"

Pull just as they start to emerge

Pro: "As soon as they move or open their eyes pull it. They don't have a chance to go wild, but you know their reflexes are intact."

Con: " This is the WORST time to pull it. If you start doing this, you will see largospasm!"

My Question(s)

In adults, how risky is it to pull an LMA during stage II? In other words, is the highest risk for larngospasm when an ETT passes through the cords (not an issue with an LMA) or is it from secretions falling onto the cords (possible issue with an LMA).

Do you guys teach your students to pull LMA either deep or awake (like with ETT) or is the risk much smaller?