Abstract:
A reversibly operable motor is mechanically connected to automatically position the piston of an air syringe that is pneumatically connected to the inflatable/deflatable seal ring or cuff of a laryngeal mask airway device (LMA) that is installed in a patient, who is being ventilated and/or anaesthetized via the airway of the LMA device. Air pressure in the cuff corrected as necessary to conform to a predetermined pressure level. The system continuously monitors for abnormal patterns of response, with audibly and visually reported warnings to the anaesthetist; these warnings include system detection of a patient&#39;s incipient sign of premature awareness while still under surgery, system detection and warning of a system or LMA malfunction, and continual microprocessor survey and integration of historical data to determine decremental recovery from administered anaesthesia.

Description:
BACKGROUND OF THE INVENTION 
   This application is a continuation-in-part of International application PCT/GB98/03849, filed Dec. 21, 1998, and with a claim of priority from original UK application No. 9727367.6, filed Dec. 24, 1997. 

   This invention relates to apparatus useful for controlling and/or monitoring the inflation pressure within a laryngeal mask airway (LMA) device and to a method and means for monitoring a patient&#39;s welfare by way of fluctuations in that inflation pressure. 
   LMA devices are now well known and are in widespread use in patient care, both during and after surgical procedures and during procedures that involve maintaining a clear airway. Such devices and their construction and use are described in various patent publications, for example, British Patent No. 2,205,499 and U.S. Pat. Nos. 4,509,514; 5,303,697; 5,241,956; and 5,282,464. 
   That such LMA devices are well accepted tools in patient care is borne out by simple statistics. For example, it is estimated that such devices are used in approximately 50 percent of all operative procedures requiring the use of general anaesthetic in the UK, and their use is becoming increasingly accepted elsewhere in Europe and in the USA. 
   Basically, an LMA device comprises an airway tube that is sized and curved for general conformance with a patient&#39;s airway; the airway tube extends from a proximal end that is external to the patient, to a distal end that carries mask structure in the form of a bowl or backing plate which faces and covers the patient&#39;s laryngeal inlet and which is continuously surrounded by a flexible ring or cuff that is selectively inflatable for resiliently sealed conformance to body structure around the laryngeal inlet. In use, the LMA is first fully deflated to aid its insertion and is then passed through the patient&#39;s mouth and throat into its correct position, with the mask over the laryngeal opening. The inflatable cuff surrounding the mask structure is then inflated to form a seal between the mask and the laryngeal opening. The air pressure with which the cuff is inflated forces the rear of the bowl of the mask against firm tissues at the back of the throat to maintain the device in place and to retain the seal. In this way, the device forms an open airway through which the patient&#39;s lungs can be ventilated. 
   Such LMA devices have proved to be both sturdy in construction and relatively straightforward to use, even by paramedics after the necessary training; however, if a mask is wrongly inserted, a reliable airway is not in fact formed and the patient&#39;s lungs are not then properly ventilated. In addition, the soft compliant silicone material of the cuff has been known to absorb nitrous oxide from anaesthetic gas mixture thereby increasing the pressure within the cuff, and the cuff itself may occasionally develop leakage causing its internal pressure to decrease. Also, it has been found that too high an inflation pressure will cause the cuff to restrict the blood supply to the mucosa overlying the muscles around the laryngeal inlet, and prolonged use of an LMA device in such circumstances can lead to tissue necrosis. 
   It has recently been proposed to monitor a patient&#39;s level of consciousness by means of a device capable of detecting and analyzing cerebral activity, in an attempt to avoid awareness during surgery; however, the equipment required for such monitoring is complex in operation and costly to manufacture. It has also been proposed to use automatic equipment to monitor intra-cuff pressure in a high-volume, low-pressure cuff associated with an endotracheal tube (EDT). And it has been reported that such an EDT device is able to measure and regulate intra-cuff pressure, to a tolerance of ±3-mm mercury. 
   We have observed that muscle tension (tone) in the lower throat (hypopharynx) bears a relationship to the patient&#39;s apparent response to painful stimuli; thus, it is possible to gain information on the patient&#39;s anaesthetic depth by monitoring muscle tone in the hypopharynx. And we have found that very small changes in that muscle tone are reflected through the LMA cuff and are further reflected through the shared air volume and that such pressure feedback readings can be utilized to both automatically adjust the inflation pressure of the LMA cuff and also to detect changes in the muscle tone in the hypopharynx. Of course, the detection of such changes is most preferably made without causing patient duress, and to such end it has been observed that it is most beneficial to inflate the cuff to pressures not much higher than 60-cm H2O; for example, 50-cm H2O, and generally in the range 25-cm H2O to 100-cm H2O. The acceptability of utilizing pressures above 60-cm H2O has been observed to cause patient throat irritation, especially in procedures of longer duration, and may risk damage to such tissue. 
   BRIEF STATEMENT OF THE INVENTION 
   The present invention has as its overall object to provide apparatus which is capable (a) of monitoring with fine sensitivity, for example 0.0625-cm H2O, the pressure within the cuff of an LMA device that has been properly installed within a patient&#39;s airway; and (b) of maintaining a preset inflation pressure within narrow tolerances, for example ±0.5-cm H2O. 
   It is also an object of the invention to provide apparatus which can be pre-programmed to recognize a variety of different patterns of pressure variation within the cuff of the LMA device and if necessary, to produce an appropriate range of different warnings to the operator in response to those patterns, and to be responsive to anomalous operating conditions threatening the integrity of the LMA device. 
   It is a specific object to provide monitoring apparatus of the character indicated, wherein, for the case of a patient who has been anaesthetized for surgery, the monitoring of LMA inflation pressure in the course of the surgery can include such automated analysis of LMA inflation pressure variation as to warn the operator that the patient has just exhibited an anomaly indicative of an incipient stage of awakening, thereby alerting the anaesthetist or anaesthesiologist (which are terms hereinafter used interchangeably) that the patient is in immediate need of further anaesthetic. 
   A further object is to provide apparatus which meets the foregoing objects, is relatively inexpensive to manufacture, is straightforward to set-up, and is reliable to operate and maintain. 
   A still further object is to achieve the foregoing pressure regulation without resort to utilization of some other form of system whose components would introduce an additional time constant or hysteresis effect on pressure monitoring functionality; such as would be caused by an accumulator-type system that is reliant upon a pumped or otherwise elevated pressure reservoir to replenish device operating pressure. 
   The invention seeks also to provide a method for maintaining a predetermined pressure in an LMA device and a method for monitoring pressure changes within the LMA device to detect changes in the patient&#39;s condition and to control the administration of anaesthetic and/or muscle relaxant. 
   A preferred embodiment of the invention meets the foregoing objects using apparatus for automatically controlling pressure in a laryngeal-mask airway device that has been installed in a patient, wherein the LMA device includes means that is inflatable to a predetermined level of pressure to establish sealed communication between the interior of the device and the patient&#39;s laryngeal inlet, said apparatus comprising: 
   (a) syringe means having a piston displaceable in an elongate cylinder with an outlet connection for supply of inflation air to the inflatable means; 
   (b) reversibly operable drive means for reversibly displacing the piston relative to the cylinder, thereby selectively displacing air to or from the inflatable means; 
   (c) control means including (i) pressure-responsive means connected for response to instantaneous pressure at the outlet connection, (ii) adjustable means for selecting a set-point value of inflation pressure, (iii) comparator means connected for response to a selected set-point value, for providing an electrical-output signal representative of the difference between instantaneous pressure and the selected set-point value; and 
   (d) means connecting the electrical-output signal for operation of the drive means to displace the piston relative to the cylinder in the directional polarity to reduce to zero or near-zero the electrical-output signal provided by the comparator means. 
   Preferably, the reversibly operable drive means comprises an electric motor coupled for reversible drive of a lead-screw and nut means threaded to the lead screw, the nut means being longitudinally guided and keyed against rotation and connected for direct longitudinal displacement of the piston in the cylinder. 
   The preferred electric motor is a stepper motor driven in the open loop mode and which operates without slip or hysteresis lag/error. The direction and speed of the motor rotation are dependent upon the sequence and frequency of the phase of applied excitation. 
   More specifically, the reversibly operable drive means comprises such a stepping motor, in which the pressure-responsive means produces a first digital-signal output, in which the set-point value is in the form of a second digital-signal output, and in which the comparator means includes a microprocessor programmed to supply digital-control signals for operation of the motor. 
   Advantageously, a first normally closed solenoid valve is connected to the outlet connection of the syringe means for interposition between the outlet connection and the inflatable means, the solenoid of the valve having electrical connection to the control means whereby to actuate the valve to open condition for at least the time duration of the electrical-output signal and as long as the electrical-output signal is other than zero. A second normally closed solenoid valve is connected to the outlet connection of the syringe means; when actuated to open condition, this second valve provides syringe access to ambient air, for adding to or dumping system air, while the first solenoid valve is in closed condition. 
   Preferably, the cylinder has a ported but otherwise closed longitudinal end; and each of the two normally closed solenoid valves is connected to serve the ported end of the cylinder. The first normally closed solenoid valve is also connected to the inflatable means of the LMA and is actuable to interchange air between the inflatable means and the cylinder pursuant to the direction of displacement of the piston; and the second normally closed solenoid valve is actuable, as described above, to admit ambient air to the cylinder or to expel air from the cylinder, depending upon the direction of displacement of the piston. First limit-switch means produces an electrical signal for a sensed condition of piston advance into a predetermined limiting proximity to the closed end, and means including a microprocessor is responsive to the signal of sensed piston proximity, the microprocessor being programmed (i) to foreclose operation of the drive means and to return the first solenoid valve to its normally closed position, then (ii) to actuate the second solenoid valve to open condition while operating the drive means for a predetermined stroke in reverse, thus inducing a fresh charge of ambient air into the cylinder pursuant to the predetermined stroke in reverse, and (iii) deactivating the second solenoid valve and enabling the comparator means to reestablish the set-point value of pressure within the cylinder before reactivating the first solenoid valve and returning the comparator means to its function of regulating LMA-inflation pressure to its set-point value. 
   In a further microprocessor-controlled feature of the currently preferred system, as for a patient who has been anaesthetized and is undergoing surgery, mask-inflation pressure is continuously monitored. The instantaneously observed mask-inflation pressure is monitored for possible traverse of predetermined upper and/or lower threshold limits of “normal” regulation; and, upon observed-pressure traverse of one of these limits, a first alarm signal is issued with an audible warning, it being interpreted that, even though still asleep and under sedation, the patient has involuntarily betrayed an indication of hypopharynx/larynx muscle contraction, with accompanying transient local compression of the patient&#39;s inflated LMA. Further automated monitoring is concurrently performed to determine whether any rate-related conditions occur, beyond a predetermined magnitude of an evaluated criterion. Such rate-related occurrences are further described below and are determined by continuous review of analyses performed on a gated sequence of several successive readings that are stored-within the system; and the output of such analyses is continually displayed at the system monitor. This rate-related analysis of observed inflation pressure provides further indication of the patient&#39;s incipient and prospective awakening process and provides verification of first alarm, further alerting the anaesthesiologist with visual warning to “check anaesthesia”. 

   
     BRIEF DESCRIPTION OF THE DRAWINGS 
     Apparatus and methods of the present invention will be described in greater detail by way of example and with reference to the accompanying drawings, in which: 
       FIG. 1  is an illustration of a control/monitor system of the invention, coupled to an LMA device installed in a patient; 
       FIG. 1A  displays a first of two typical readouts of a percent-awakening feature, which may comprise a portion or all of a display screen; 
       FIG. 1B  is a similar display for a second and subsequent readout of the percent-awakening feature; 
       FIG. 2  is a diagram of mechanical components of  FIG. 1 , with schematic indication of motor-control components; 
       FIG. 3  comprises separate sheets labeled  FIG. 3  (Part A) and  FIG. 3  (Part B), and is a more schematic diagram of control means including a comparator component and motor-control circuit for the system of  FIG. 2 , wherein measured pressure is evaluated against a set-point SP for determining drive for an air-displacing piston and is further evaluated against thresholds for determining status of pain-stimulus alarms; the phantom line  3 A of  FIG. 3  (Part A), and the phantom line  3 B of  FIG. 3  (Part B) represent one and the same plane at which  FIG. 3  (Parts  3 A/ 3 B) are connected to complete  FIG. 3 ; 
       FIG. 4  is a schematic of means by which the system can transfer between start-up, centering, and reset circuitry; 
       FIG. 5  is a graphical display of system-observed pressure variations as a function of time in the seal cuff of an LMA that is installed in a patient who has been anaesthetized and is undergoing surgery, but has, as yet, had no pain stimulus; 
       FIG. 5A  is a graphical display as in  FIG. 5 , just before and following display of system response to an illustrative anomaly that reflects a pain stimulus; 
       FIG. 6A  and  FIG. 6C  are tables detailing typical calculations performed on sampled test data, comparing these values to set-point, and performing rate-related alarm calculation for each sample; 
       FIG. 6B  and  FIG. 6D  are graphical representations of the values presented on  FIG. 6A  and  FIG. 6C ; and 
       FIG. 7  is a display of observed empirical data obtained during the awakening sequence of a patient; such data providing an example of a pain-stimulus response that is revealed by analysis of the monitoring function of the system. 
   

   DETAILED DESCRIPTION 
   A. Mechanical Construction and Operation 
   In  FIG. 1 , the monitoring system or device of  FIG. 2  is shown at  10  with various control buttons including a system start/stop button  52 , a “regulation” start/stop button  53 , an alarm-reset button  54 , an “ENTER” button  55 , and a rotary knob  56  for selection, inter alia, of set-point or threshold. 
   The monitoring system  10  has an outlet connection to the flexible inflation/deflation air-supply line  11  of an LMA device  12  installed in a patient  13 . The LMA device  12  is seen to comprise an airway tube  14  with proximal-end means  15  for external accommodation of ventilating or anaesthetizing supply to the patient&#39;s lungs via mask structure  16  having a backing plate  17  connected at  18  to the distal end of tube  14 , the backing plate being peripherally surrounded by an inflatable/deflatable ring or cuff  19  of resiliently flexible material; cuff  19  is shown in inflated condition, in peripherally sealed relation to body structure surrounding the patient&#39;s laryngeal inlet  20 , and in distally located relation to the patient&#39;s aesophageal inlet  21  (the hypopharynx). Internal structure of the mask will be understood to include known means (not shown) to prevent the patient&#39;s epiglottis  22  from interfering with air or anaesthetizing flow through the mask, in either direction, between tube  14  and the patient&#39;s laryngeal inlet  20 . 
   Conventionally, the inflatable/deflatable ring or cuff  19  of an LMA device is operated manually by a hand-held syringe (not shown) that is detachably connected to check-valve means  11 A forming an outer end of line  11  of the LMA; when the syringe is detached, the check-valve means  11 A is operative to retain the currently inflated or deflated state of the LMA. By experience, the anaesthetist will know roughly to what pressurize the cuff can safely be inflated once the LMA has been properly installed in the patient. Although the control system can be utilized to inflate the cuff after it is installed in the patient, especially with the smaller cuff sizes, the above described manual procedure of inflation is recommended prior to connecting the LMA inflation/deflation line  11  to the control system of  FIG. 2 . 
   In  FIG. 2 , an air-control port  11 ′ will be understood to include suitable means for detachable connection to the inflation/deflation air line  11  of  FIG. 1 ; and an elongate flexible connection or extension line  11 B has (i) a system-connector end (not shown) that is detachably connected to control port  11 ′, and (ii) an LMA-connector end that is compatibly connected to so coact with the connector end of the check-valve means  11 A as to maintain lines  11 / 11 B as a continuously open passage of system communication with inflatable means  19  of the LMA. Air-displacement means may comprise syringe means in the form of a solid body  25  of low-friction material such as PTFE (Teflon) with a cylindrical bore  26  having an open (or tail) end for coaction with piston means  27 ; but it is currently preferred that body  25  be of stronger material such as aluminum, with a lubricant and/or anti-friction coating in the bore  26  of the cylinder for sealed engagement with a resilient O-ring or lip carried by and effectively forming part of piston means  27 . Body  25  is fixed to a frame member  28  and extends longitudinally to a closed (or head) end having a port connection  29  to a direct line to the LMA inflation/deflation connection means  11 ′; in this direct line, a first normally closed solenoid valve V 1  must be actuated to open condition if inflation air is to pass in either direction between cylinder  26  and the inflatable/deflatable means  19  of the LMA. 
   Piston  27  is rigidly mounted to or formed with the head end of a longitudinal rod  30 , the tail end of which is clamped to a slide block  31 . Block  31  establishes a rigid lateral-offset arm for longitudinally stabilized guidance at  32  and for reversibly driven longitudinal displacement by frame-based electrical stepper motor means  33  and its lead-screw output shaft  34 ; shaft  34  has threaded engagement to a nut-like bore  34 ′ in the rigid lateral-offset arm of slide block  31 , and preferably the threaded bore  34 ′ is formed in a body of PTFE that is secured to slide block  31 . The guide means  32  will be understood to be a schematic designation for a commercial longitudinal “linear-bearing” assembly (widely known and available under the name or mark “ROLLON”) wherein an elongate first raceway element is fixed to a frame member, wherein an elongate second raceway element is fixed to the slide block  31 , and wherein antifriction elements, such as bearing balls, ride and space the raceways of the respective raceway elements. The described arrangement of longitudinal support and guidance afforded by means  32  will be seen as establishing precise longitudinal displaceability of piston  27  along the central longitudinal axis of the cylindrical bore  26 , with block  31  and piston  27  effectively keyed against rotation about the lead screw. 
   Motor means  33  is of a stepping variety wherein a precise directional control is effected via variance of the relative excitation of each of-four input terminals of the motor. The amount of shaft  34  rotation (and thus of piston  27  displacement) is controlled by motor controller and driver means  47 , as shown in  FIG. 2 . 
   Legends in  FIG. 2  indicate an overall length L of piston  27  travel in bore  26 , for purposes of delivering inflation air from bore  26  to the inflatable/deflatable ring or cuff  19  of the LMA, as long as solenoid valve V 1  remains actuated to open condition; this same length can also be available for a retraction stroke of piston  27 , wherein a controlled quantity of inflation air may be extracted from cuff  16 . Fixedly mounted limit switches LS 1  and LS 2  are schematically indicated by arrow marks in  FIG. 2 , to suggest a stop and/or reversing device at each of the longitudinal limits of the overall length L of piston travel. However, as shown in  FIG. 2 , piston  27  is at offset ΔL outside of the cylindrical bore, wherein the arrow designated LSO identifies the point at which a coacting lug or other switch-actuating device  37  carried by piston rod  30  coacts with limit switch LSO to electrically or otherwise signal achievement of the piston-retracted position shown, with concomitant termination of drive pulses from driver circuit in  FIG. 3 ; suitably and preferably, each of the limit switches is an optical device, relying on the lug or other actuating device  37  to be opaque and therefore able to cut or interrupt a light beam, from a source to a photocell, at each of the respective locations at which limit switch action is to occur. 
   As further shown in  FIG. 2 , the head end of piston rod  30  has a radial flange formation  38 , circumferentially shrouded by a resilient cap  39 , having an undercut bore which readily snaps into resiliently retained engagement to the flange formation  38 , as when servicing the apparatus by replacing a used cap  39  with a new cap  39 ; it will be understood that the lip relied upon for sealed engagement to bore  26  may be an integral formation of cap  39 . 
   Some pressure-regulating operations can have the effect of causing interference with the sensing of pressure changes reflecting patient muscle reflex. The system of the invention has been designed to minimize such interference through its design concept as an essentially closed-volume system, wherein adjustments for cuff  19  pressure deviation are made by increments of displacement within a shared volume of air, as between (i) the volume ahead of the piston  26  and within the head end of the cylinder and (ii) the volume in the cuff  19 . This is superior to systems that regulate pressure by using an accumulator or reservoir of elevated pressure to compensate for cuff pressure changes either by introducing air from such an accumulator or by voiding air to atmosphere. 
   The inherent increase in system stability resulting from use of the shared-volume concept that is utilized by the system of the invention allows a high degree of accuracy without associated system hunting or over-adjustment. Specifically, approximately 0.0005 ml (0.5 micro-liters) of air is moved with each step taken by stepper motor  33 . Such performance is presently not available for a pressurized accumulator-type system. 
   Further elements of the apparatus of  FIG. 2  comprise first P 1  and second P 2  pressure-monitoring transducers. These pressure transducers, which indicate the overall pressure in the device, are connected to redundantly monitor air pressure in the line between cylinder-outlet port  29  and the normally closed first solenoid valve V 1 . 
   A second normally closed solenoid valve V 2  is shown connected to the air line between cylinder port  29  and the first solenoid valve V 1 . When actuated to open condition, valve V 2  establishes a path from its open-air end  44  to the air line from cylinder port  29  to the first solenoid valve, so that, with valve V 1  in its closed unactuated condition and with valve V 2  actuated to its open condition, a right-to-left displacement of piston  27  in cylindrical bore  26  will induce an inflow of fresh (ambient) air into the described system. Similarly, with the two valves V 1  and V 2  in the same condition (of V 2  actuated and of V 1  in its normally closed condition), a left-to-right displacement of piston  27  in bore  26  will discharge excess air or gas from the system. 
   Also, and analogously, with valve V 2  in its normally closed condition and with valve V 1  actuated to its open condition, a right-to-left displacement of piston  27  will draw inflation air from (and thus deflate) means  19  of the LMA. And for the same conditions of valve V 2  unactuated and of valve V 1  actuated, a left-to-right displacement of piston  27  will supply inflation air to means  19  of the LMA. Control signals necessary for actuation of valves V 1  and V 2  are provided by separate outputs that are derived from basic program-sequencing signals from a separate microprocessor means of a controller  60  for start-up, centering, and reset. 
   A.1. System Start-Up 
   For purposes of system start-up and centering operations, the control circuit of  FIG. 3  is bypassed and the inputs to stepper motor controller and driver  47  are controlled by the controller  60  for start-up, centering, and reset. As shown in  FIG. 4 , the bypass of the  FIG. 3  control circuit is accomplished by the operation of two single-pole, two-position switches  42 . Such operation of switches  42  will occur when the unit is first powered up, at which point a start-up sequence is initiated. The operation of stepper motor  33  is controlled during start-up sequence by controller ( 60 ) for start-up, centering, and reset. 
   Before proceeding with illustrative description of automated operation of the regulating system of  FIGS. 1 and 2 , it is noted that for practical purposes, the system must compatibly operate with suitably sized LMA&#39;s for patients of all ages, requiring ring  19  inflation volumes which will differ by as much as 10:1 between extremes. The sizes currently available for the anaesthetist&#39;s selection are as follows:
         Size 1 (small infant), 4 cc maximum inflation volume.   Size 1.5 (larger infant), 6 cc maximum inflation volume.   Size 2.0 (small child), 10 cc maximum inflation volume.   Size 2.5 (larger child), 14 cc maximum inflation volume.   Size 3.0 (small adult), 20 cc maximum inflation volume.   Size 4.0 (average adult), 30 cc maximum inflation volume.   Size 5.0 (large adult), 40 cc maximum inflation volume.       

   It is currently preferred to design the displacement-volumetric capacity of the syringe bore  26  to be substantially 20 cc, between LS 1  and LS 2  operations at the respective extremes of piston displacement L in bore  26 ; for a bore  26  diameter of 24 mm, the displacement-volumetric capacity of 20 cc is realized by a full-stroke displacement L of about 45 mm, which can be taken as the illustratively useful displacement range of the system. Further illustratively, for a stepping motor  33  designed to require 1600 pulsed steps for a single revolution of its lead-screw  34 , and for a lead-screw pitch (i.e., advance per turn) of 2 mm, the useful range L of piston  27  displacement involves 36,000 discretely pulsed step increments; for initial set-up purposes, a recommended “fast” repetition rate of pulsed steps at 5,000 Hz is to be applied to produce a piston-displacement speed of 6.25 mm/sec. For normal pressure-regulating displacements, a recommended “slow” repetition rate of pulsed steps at 500 Hz is to be applied to produce a piston-displacement speed of 0.625 mm/sec. It is explained below that any automatic pressure-regulating correction is preferably achieved by an increment of piston displacement, wherein the increment begins from the mid-point of the useful range L, so that the indicated regulating range of motor displacement is normally accomplished within the scope of 18,000 pulses to motor  33 , thus enabling a volume displacement of at least 10 cc, in the LMA-inflating direction or in the LMA-deflating direction, as needed. For automated regulation of LMA inflation to set-point pressure, this range limitation is found to serve any of the above-noted LMA sizes, even though the range of inflation volumes is about 10:1. 
   It has been recommended above that the system of  FIGS. 1 and 2  be connected (at  11 ′) to the inflatable means  19  of the LMA only after having followed the conventional procedure of using a hand-held syringe (not shown) to evacuate means  19  for purposes of LMA insertion in a patient, and for then using the same syringe to effect an inflation which the operator knows from experience will establish a properly located seal of means  19  around the laryngeal inlet, and with distally contacting engagement with the hypopharynx. 
   The preferred method of initially inflating LMA ring  19  is for the anaesthetist to use syringe means. Whether or not the LMA inflation ring  19  is inflated manually, the system of  FIGS. 1 ,  2  and  3  is adapted to quickly assume pressure-monitoring control of inflation ring  19  to the predetermined set point, which will be understood to present a desired pressure set-point value SP (e.g., 50-cm H2O) as part of the display  49 . Although the LMA control system  10  is capable of performing the initial task of cuff inflation, such initial inflation by the system  10  may be practical only for cuffs of smaller volume capacity and is not presently preferred. 
   Thus, with pressure threshold set-point SP selected and established for the system of  FIGS. 2 and 3 , programmed operation will begin with the controller  60  (for start-up, centering, and reset) controlling the initial start-up sequence. The controller  60 , as shown in  FIG. 4 , contains an algorithm that actuates valve V 2  to open condition, leaving valve V 1  in its unactuated (and therefore in its normally-closed) condition. Pulses are then sent at high speed (5,000 Hz) via stepper motor controller and driver  47 , operating motor  33  to displace at high speed piston  27  from its retracted position, which is determined by lug  37  coaction with limit switch LSO. Piston  27  rapidly traverses the full range (L) of piston  27  travel in bore  26  in left-to-right motion. In the course of this traverse, lug  37  will actuate limit switch LS 1 , thereby initiating in the stepper motor controller and driver  47  a count of number of pulses that are required to drive the piston as a function of displacement L. The count is terminated only when lug  37  actuates limit switch LS 2 , at which point the full count is entered into memory of controller  60 , and an automatic divide-by-two operation is effected, with its half-count value entered into memory of the controller  60  and also entered into memory of the stepper motor controller and driver  47 . Thereafter the stepper motor controller and driver  47  will track each subsequent command that operates motor  33  to independently maintain an awareness of piston  27  position. 
   A signal is then sent by the controller  60  for travel to start in the opposite direction at the same high rate of speed until a pulse count is reached indicative that piston  27  has reached its mid-position (or “L/2”). Valve V 2  is then deactivated, returning it to its normally-closed condition. 
   Both switches  42  in  FIG. 4  then simultaneously transfer from the first (“1”) position to the second (“2”) position, thereby allowing a fuzzy-logic controller  46 , shown in  FIG. 3 , to assume control of motor  33 . The fuzzy-logic controller  46  will operate in accordance with logic rules set forth below in Table 1, providing the signal necessary for piston  27  to continue its travel in the left-to-right direction until pressure generated at the head end of the cylinder  26  equals a preprogrammed check-point pressure, typically 20-cm H2O; and once such value has been attained, for reasons explained in the following section, piston  27  will be further actuated to continue its travel until the set-point value SP has been attained. The controller  60  will then actuate valve V 1 , transferring V 1  to open condition. 
   Should the controller  60  (for start-up, centering, and reset) fail to receive indication that the preprogrammed check-point pressure has been attained within a predetermined number of stepper motor ( 33 ) steps (e.g., the preprogrammed check-point pressure to be attained prior to travel of the number of steps required for piston  27  to traverse one-eighth (⅛) of displacement L), an audible and visual alarm will issue and the system will prohibit automatic system operation. 
   A.2 Failsafe Mode 
   A failsafe mode may be triggered during the course of regular system operation upon substantial deviation between the redundant pressure sensors. The pressure is redundantly sensed by pressure transducers P 1  and P 2 , from which independently sensed pressure readings are continuously compared by a comparator means “A”  40 . A hardware-error HW alarm will be generated when a difference other than substantially zero is detected between P 1  and P 2 . This hardware-error alarm is issued in the form an audible and visual indication, alerting the anaesthesiologist to assume manual inflation control of the LMA. Then, a short period of time after issuing such hardware-error alarm, comparator means “A”  40  will go to failsafe mode, closing V 1  and V 2  in order to maintain the pressure within the LMA cuff. 
   B. Normal System Control 
   Fuzzy-logic controller operation is described by the logic rules set forth below in Table 1. The first two columns in Table 1 reflect the previous pressure and the current pressure, each as compared to SP. As noted in  FIG. 3B , the delay time between the first and second columns is one-half (½) second. The last column in Table 1 reflects the command that will typically be sent by the fuzzy-logic controller  46  to motor controller  47 . Because during normal operation the stepper motor  33  operates only at slow speed, the fuzzy command is sent in terms of direction and number (N) of steps. The described pressure-regulating process that is conducted by the fuzzy-logic controller preferably performs its task within a range of operation defined by a deadband of 0.5-cm H2O on each side of the set-point SP. 
                                     TABLE 1                   Operation of Fuzzy Logic Controller 46                Previous                   Actual                   Pressure in   Current Actual   Decision in           relation to Set   Pressure in relation   Steps (N) and           Point   to Set Point   Direction                       High   High   High number of                   steps, reverse           Medium   High   High number of                   steps, reverse           High   Medium   Low number of                   steps, reverse           Medium   Medium   Minimal number of                   steps,                   bi-directional           Low   Medium   Low number of           Low   Low   High number of                   steps,                   forward           Medium   Low   High number of                   steps, forward                        
C. Typical Waveform for an Anaesthetized Patient
 
     FIG. 5  illustrates a respiratory waveform which the system of the invention has used both to regulate pressure of the LMA cuff  19  and to monitor the LMA-inflation pressure. The patient in this example is under surgery and is being mechanically ventilated, i.e., the patient&#39;s ventilation is the result of positive pressure being exerted through airway tube  14 , also referred to as intermittent positive-pressure ventilation, or “IPPV”.  FIG. 5  depicts the ability of the device of the invention to monitor oscillations (fluctuations) about the set-point SP (50-cm H2O in this example), wherein such oscillations occur at a rate of approximately twelve cycles per minute, which is typical of the respiratory cycle of a “normal” anaesthetized adult patients. 
   It has been discovered that such respiratory flow, through airway tube  14  , whether spontaneous or by IPPV, will have the effect of causing the LMA cuff  19  to undergo regular cycles of compression/expansion. One of the objects of the system of the invention is to measure the magnitude of both the compression/expansion cycles as well as to detect deviations from such compression/expansion cycles as can be determined to indicate pain stimuli. Although there is an overall expansion of the  FIG. 5  signal envelope (as such is shown in  FIG. 5  and which will be further explained below in the section on autoscaling), there are not as of yet any indicia of pain stimuli in  FIG. 5 .  FIG. 5A  provides an example of the patient experiencing a pain stimulus, which the system of the invention will detect and report via alarm procedures that are the subject of discussion below. 
   The graph of  FIG. 5A  is illustrative of competing forces at play, once disturbed by reaction to a pain stimulus of the character indicated. First of course, one is reminded that the system of the invention will have been in its normal “regulating” mode, doing what it can, based on its repeated sampling (at 0.5-second intervals) of measured pressure (e.g., P 1 ) in relation to the set point SP and using this reading to determine and make the proper displacement of piston  27 . The pattern of neuromuscular-derived pressure variations which follow a pain stimulus, and piston displacements that will be called for and may not be within the capacity of described mechanism to track, can therefore create a disturbed pattern of measured pressures while the regulating mode is attempting to reestablish itself. Still further, the normal regulating mode and the patient&#39;s neuromuscular system will be attempting to adapt to changed and changing conditions, as may result from the patient&#39;s neuromuscular response to a deepening (“rescuing”) further dose of anaesthesia. 
   D. Monitoring Function 
     FIGS. 3 ,  5 , and  5 A, and the charts and tables  FIGS. 6A ,  6 B,  6 C, and  6 D, serve for illustration of two automatic techniques whereby the device of  FIGS. 1 ,  2 , and  3  can alert the anaesthetist that, during the course of a surgical operation on an anaesthetized patient, the patient has given an early neuromuscular indication of a pain stimulus which the patient&#39;s current anaesthetized level has been unable to block, even though the patient is still sufficiently sedated to be unconscious or otherwise unaware of the pain stimulus. Such neuromuscular indication demonstrates to the attending anaesthetist that the patient is contracting muscles of his larynx and hypopharynx—a phenomenon indicative of an incipient stage of the patient&#39;s awakening process—with potentially serious consequences if the surgical procedure has not yet been completed. 
   Although it is known that patients under the effect of a general anaesthesia become insensitive to pain stimulus, such sensitivity has been discovered to be particularly active and observable at muscle systems surrounding the laryngeal inlet and the hypopharynx area. It has been further discovered that such activity of these muscle systems will vary with the depth of anaesthesia and can be observed by pressure fluctuations in an inflated LMA cuff  19  having resiliently loaded continuous contact with such muscle systems. Specifically, anomalous pressure readings in the output of pressure comparator “A”  40  are recognized by comparators “B”  57 , “C”  58 , and “D”  59  in  FIG. 3  to develop output alarms A 1  and A 2 . The inflated ring or cuff  19  of the installed LMA is thus the means of early detection of a localized neuromuscular response, which is deducible from a sudden reaction of the regulating function of the described system, as the same is seen to occur in the disturbed and irregular pattern of pressure excursions in  FIG. 5A , wherein bracketing and legend identify a period of pain stimulus due to an event occurring during a surgical procedure. 
     FIG. 7  displays empirical values of the varying pressure fluctuations that were observed to occur as the anaesthetist intentionally allowed the patient to partially revive from the depths of anaesthesia, it being understood that a chart similar to  FIG. 7  was available in real time on display  49  during the course of the surgical procedure. The pressure changes are displayed on the ordinate in cm H2O, with the set-point SP having been selected at 60-cm H2O.  FIG. 7  displays events that transpired toward the conclusion of a surgical procedure in which the patient, “Patient 5”, was anaesthetized with a continuous feed of propofol, a common and popular anaesthetic. 
   Three specific time periods are recognizable in  FIG. 7 , and each of these intervals corresponds to the initiation of a variance in the amount of anaesthetic administered to Patient 5. In the first of these periods, beginning at time 68-minutes, the continuous administration of propofol was stopped. And in an ensuing remainder of the first period, a significant increase in activity of muscles in the larynx/pharynx area is readily observable in the region contacted by the LMA cuff  19 . 
   Correlation of increased muscle activity (in the larynx/pharynx region) to the patient&#39;s depth of anaesthesia has been discovered to be of significant benefit in maintaining proper anaesthesia levels during the course of surgical and other proceedings. Use of the LMA device and monitoring apparatus provides means by which such observations can reliably be made with the additional benefit of hot subjecting the patient to further intrusive apparatus. 
   During the second period marked in  FIG. 7 , the beginning of which occurred at approximate time 72-minutes, the anaesthetist restarts the administration of propofol. The third period in  FIG. 7 , starts at approximate time 73-minutes, and identifies when the administration of propofol was again stopped, and the patient was allowed to fully awaken. Note that there are no further readings after approximate time 82-minutes, because the LMA was at that time removed from the patient&#39;s laryngeal area. 
   The events displayed in  FIG. 7  provide clear evidence that the monitoring system of the invention functions at a level of sensitivity permitting detection of muscular activity indicative of the awakening sequence. 
   D.1 Automated Alarms 
   Two techniques recommended for automatic interpretation of the anomaly described in  FIG. 5A  are further described below. These alarms can be monitored by the anaesthetist for immediate or early recognition of the pressure anomaly that has been observed as a symptom caused by an early incipient stage of the patient&#39;s awakening process. 
   Both techniques rely upon the establishment of fluctuation boundaries (thresholds) on each side of the normal respiration waveform and the comparison of LMA (ring  19 ) pressure to such limits; these are shown as upper and lower thresholds E 1  and E 2  in  FIGS. 5 and 5A  and are referred to as the “check anaesthesia alarm window”. As shown in  FIG. 3 , E 1  and E 2  are the values automatically compared to each pressure signal fluctuation for determination of the anaesthesia-level alarms, A 1  and A 2 . The attending anaesthetist is able to individually select, i.e., to vary E 1  and E 2  via monitoring device  10 . A 1  is an instantaneous-type alarm, triggered whenever the respiration waveform deviates above or below the “check anaesthesia” alarm window that is framed by E 1  and E 2 . The initial warning alarm A 1  is triggered by any single deviation from the “check anaesthesia” alarm window. The A 1  alarm will be presented to the anaesthesiologist in audible form. Once thus warned, the anaesthetist is alerted to make an immediate corrective response, as by increasing the strength of the anaesthetic being administered to the patient. 
   Alarm A 2  is a rate-related alarm that is determined (i) by a window-related value ET (explained below) and (ii) a calculated mean (Y) based on successive samples of the detected waveform of varying LMA-inflation pressure, wherein the samples are taken for each successive 0.1-second sampling interval, and are effectively integrated and stored as absolute values in a word-summing array circuit, as shown in  FIG. 3 ; each of the absolute values is taken for its sampled magnitude with reference to a steady base line, conveniently the set-point value, as shown in  FIGS. 6A and 6B . If the mean value, i.e., the sum of the most recent successive thirty-two integrated samples, divided by 32 ( 61 ,  FIG. 3A ), exceeds the value ET, as further explained below, the A 2  alarm will issue, such as “CHECK ANAESTHESIA”, to the anaesthetist by a combination of visual and/or audio signals. The anaesthetist is thereby further alerted to make an immediate corrective response, as by increasing the strength of the anaesthetic which is being administered to the patient. ET is calculated by adding the absolute values of E 1  and E 2 , and dividing the sum thereof by a selected constant k, i.e., 
               E   ⁢           ⁢   T     =       1   k     ⁡     [     |   E1   |     +     |   E2   |         ]         ,         
wherein k is a selected value in the range 3 to 6 (and preferably 4), it being explained that with k=4, the “divide-by-4” relationship establishes a preferred practical safety factor by means of which the “CHECK ANAESTHESIA” alarm is reliably issued even though the instantaneous-type alarm A 1  may not have issued.
 
   As shown in  FIG. 3 , at the conclusion of each 3.2-second sampling period, the oldest sample is discharged and the latest sample is incorporated in the new calculation of mean value for the next 32-sample comparison to ET. 
   Thus, for example, the anomaly depicted in  FIG. 5A , which is illustrative of a pain-stimulus event observed in a surgical procedure, will be seen to give rise to determinations which are major departures from the normal situation depicted in  FIG. 5 . If an initial sample traverses one of the boundaries of the alarm window, the first alarm A 1  will be triggered, and the second alarm A 2  may not immediately be triggered. However, the integration and mean-value development described above can result in a “CHECK-ANAESTHESIA” alarm A 2 , even if a threshold-traverse needed for the first alarm A 1  may not have occurred. In addition to these two alarms, the anaesthesiologist may monitor continued progression in the form of percent awakening that can be displayed as shown in  FIG. 1B , the same being discussed below under the heading, “Display Features”. 
   Although the graph of  FIG. 5A  reflects interplay of various reactions, it is particularly noted that, once such reactions are detected, major transient departures from the set-point SP are eliminated within substantially 30 seconds by prompt administration of additional anaesthesia. 
   D.2. Display Features 
   The display  49  contains a window of time through which the continuously varying signal, such as that shown in  FIGS. 5 ,  5 A,  6 B,  6 D, and  7 , will show the latest single full minute of regulated pressure variations, passing into the window at its left-hand margin, and passing out of window viewability at the right-hand margin. 
   An additional method for displaying the results of the above-described integration/summation process (mean value) is shown in  FIG. 1A  and  FIG. 1B , where these two displays in the course of time indicate a progression, from a deeper level of anaesthesia, shown in the first example  FIG. 1A , to an incipient level approaching awakening, shown in the second example  FIG. 1B . The display preferably consists of a bar chart that shows, as on a percent scale, the output of the successively integrated function described above. The initial value of this continually-updated display is established for each individual patient, preferably after the anaesthetized patient is positioned by the surgeon on the operating table, in readiness for surgery. The parameter equivalent to a 100% display reading will equate to the full value of ET, at which point the “CHECK ANAESTHESIA” alarm will issue. 
   Also provided for utilization by anaesthetist and/or other personnel studying a particular surgical procedure is the ability to connect separate microprocessor or other data-presentation means to a computer interface  41 , thus providing for the monitoring, recording and analysis of system indicators on separate electronic media, as when more sophisticated recording and analyses are desired. 
   D.3. Autoscaling of Alarm Window 
   It has been discovered that the monitoring function of the system of the invention can be made more efficient by allowing the size of the check-anaesthesia alarm window to be automatically reduced (or autoscaled), thereby providing an advantage of faster alarm threshold (i.e., E 1  and E 2 ) adjustment and therefore more accurate monitoring of anaesthesia level. To accomplish such autoscaling of the check-anaesthesia alarm window, both the upper and the lower peak amplitudes from at least eight consecutive waveforms are sampled, averaged, and mean values for the upper and lower peaks are determined. Two checks for validation of peak values are used; all eight upper and lower limits that are sampled must be obtained during the same two-minute sampling period, and small oscillations that may otherwise be identified as peaks can be eliminated by operator input of a preset minimum amplitude. 
   These upper and lower peak amplitudes define, in essence, an “envelope” that typically decreases in accordance with the patient&#39;s compliance to positive pressure ventilation (IPPV), as the patient becomes more anaesthetized. In considering the usefulness of a need to reestablish alarm thresholds in the sense of following an envelope of decreasing amplitude (or size), it must be remembered that the patient&#39;s respiratory pressure is commonly reduced as the patient becomes more compliant. Limiting the alarm thresholds (i.e., E 1  and E 2 ) has been found to be an effective and desirable method for automatically reestablishing the sensitivity of the monitoring device so that pain-stimulus derivation will continue to be detected, despite a reduction in envelope size. 
   As a safety consideration, the preferred device will allow the autoscaling feature only to reduce, and not to automatically enlarge, the check anaesthesia alarm window. 
   The amount by which autoscaling can vary E 1  and E 2  is fully adjustable between zero and one hundred percent, with a default value of fifty percent. It is interesting to note that such autoscaling frequently causes E 1  and E 2  to no longer be symmetrical about set-point SP, similar to the alarm window shown in  FIG. 6B . 
   D.4. Re-Centering Operation System 
   As described above, the system of the invention will automatically compensate for leaks and gains in monitored inflation air. Because the stepper motor controller and driver  47  maintain a count of direction commands issued to the stepper motor  33 , the stepper motor driver  47  is able to and will so indicate when piston  27  has reached an end of its travel. Such-indication will operate switches  42  to position “1” and trigger the initiation of a “reset” function governed by the controller  60 , for start-up, centering, and reset. Depending on the reset command sent by motor controller  47 , i.e., when an anomalous condition requires a replenishment or purge of piston air, appropriate action will be taken by the controller  60 . For example, when the reset function requires that air be added to the system, the controller  60  will (i) deactivate solenoid valve V 1 , returning it to its normally closed state; (ii) activate solenoid valve V 2  to an open condition; and (iii) send appropriate signals to stepper motor controller and driver  47 , thereby causing piston  27  to be driven by motor  33  at high speed to exhaust excess “air” (or, where appropriate, taking in additional fresh air) via port  44 . The memory of the controller  60  will have retained from the system start-up procedure described above, the number of pulses required to drive piston  27  to its or midposition (L/2). 
   In normal monitoring and regulatory operation of the described system, there will be little call for great displacements of piston  27 . But large displacements can occur, for example, a loss of monitored inflation air may be caused by surgical-knife contact with the inflated LMA ring  19 . This condition will be observed by the system, calling for continued supply of either additional or reduced inflation air depending upon whether lug  37  coacts either with limit switch LS 1  or LS 2 , thereby indicating that piston  27  has reached the end of its travel. Such limit-switch signal will cause: (i) switches  42  to bypass the  FIG. 3  control circuit; (ii) the sending of an alerting notice to the anaesthetist, as in the form of an audible alarm, with visual display of the message, “CHECK FOR LEAKS”; and (iii) the triggering of the reset function of controller  60 , as is described above. 
   The above description highlights an additional advantage of the automated device in that it will, as described, replenish the volume of air in cylinder  26  within approximately 7.2 seconds, which is significantly faster than typically possible by manual operation. Despite such favorable automatic recovery time, the pressure adjustments made by the system are sufficiently discrete to allow pressure regulation of the smallest LMA cuff without causing undue pressure rebound within the small volume. 
   All such operations are automatic, as are the warnings or alarms that are part and parcel of assuring maintenance of set-point pressure, for as long as the circumstances may require for a given patient, or for a given LMA size that the patient is deemed to require. 
   CONCLUSION 
   The described device and its method of use will be seen to have achieved all stated objects, acting as a controller of LMA-cuff pressure, as a device that will monitor and correct for leaks, as a monitor of a possible pain stimulus to the patient&#39;s neuromuscular system while the patient is anaesthetized for the course of a surgical procedure, and as a monitor to prevent a patient from remaining under the effect of a muscle-relaxant while not being adequately anaesthetized. In particular: 
   1. The device is controlled by a microprocessor unit which performs all tasks including, but not limited to, diagnostic checks, motor and valve operation and control, and pressure measurement. 
   2. The device includes a graphic display and control unit as well as an interface for advance monitoring and control thus permitting data evaluation with different commercial software packages. 
   3. The device provides instantaneous values of LMA-cuff pressure via redundant pressure sensors that are pneumatically connected to the inflation line of the LMA cuff. For safety reasons, the pressure measurement is taken by redundant transducers, of which an automatic comparison is continuously performed. 
   4. The device normally operates with the same volume of air, seeking maintenance of set-point pressure for LMA-cuff inflation, wherein for each sampling measurement of LMA-cuff pressure, departure from set-point value causes piston displacement in the direction to reduce to zero (or to substantially zero) the departure of measured pressure from set-point pressure. 
   5. The device is so detachably connected to the inflation/deflation air line of the LMA as to permit normal LMA-patient installation procedures, without relying upon any of the automatic features of the device. As a consequence, the patient may be “prepped” for the operation by having the LMA installed, with inflated cuff, and completely checked to assure that it has been properly installed, before the patient enters the operating room, thus relying on a check valve to hold inflation pressure, prior to device-connection of the patient and the inflated-LMA cuff. 
   6. If, for any reason, the system is-not working or is not working properly, the system will revert to a fail safe mode, with operational valves returning to their normally closed condition, thereby maintaining LMA inflated-cuff pressure. 
   7. In its normal regulation mode, system-pressure sampling is at every one-tenth ( 1/10) of a second, with ample time to accomplish evaluation against set-point pressure, and issuance of a train of pulses is for such piston displacement as will achieve a measured-pressure correction to substantially set-point pressure. Normal regulation occurs if evaluation of a pressure sample exceeds a threshold value of ±0.5-cm H2O from an adjustable set-point value. 
   8. It is important to emphasize that normal operation of the described LMA system exhibits major advantages which flow from the fact that the system works with a virtually closed volume of air. An increase of measured pressure will rapidly cause displacement of a portion of the volume of air from the LMA cuff and into the volume defined between the piston and the head end of the cylinder; and this volume of air will be returned to the LMA cuff virtually as soon as measured pressure is detected to have decreased. This sharing of the same volume of air is always true, except when, due to a leak or to some other unexpected event, the piston reaches the end of its travel, as such is tracked by position-counter operation maintained within the stepper motor controller or upon reaching of one of the limit switches, at which point the piston will be repositioned, with an air discharge or an uptake of fresh air, as the occasion may dictate, all while the LMA cuff can retain its inflation pressure. 
   9. Once stabilized, the described system is found to be sensitive to very small pressure variations (in the order of 1/16-cm H2O) and can be quick and precise in its response without contaminating the monitoring function with time constant or hysteresis transients. It is believed that such response is achieved because of the described stepping motor and lead-screw drive, in combination with normal regulating displacements within the virtually closed volume of air. Reliance on the virtually closed volume of air translates into involvement of only one time constant in the increasing or in the decreasing of intra-cuff pressure in the LMA. 
   10. As an aid to the anaesthesiologist and in the course of a surgical procedure on a patient, the described system permits several concurrently operative algorithms to process, in real time or in close to real time, the anaesthetized patient&#39;s initial, incipient and totally involuntary muscular symptoms of arousal from induced sleep and/or paralyzed state, via sensitive response to muscular action observed around the patient&#39;s laryngeal inlet and/or at contact with the patient&#39;s hypopharynx. Provision is made for audibly and visually alerting the anaesthesiologist to detected approach of patient awakening, in good time to “check anaesthesia” and to institute corrective measures without patient awakening. The described system is seen to be inherently capable of adapting itself to enhanced precision of detecting loss of depth of anaesthesia as it progressively narrows the focus of its attention to a predetermined margin of safety in evaluating observed fluctuations in LMA-inflation pressure. 
   11. The monitoring function of the described system may be useful in detecting and providing means to guard against a circumstance in which the patient, who has been administered both an anaesthetic and a separate muscle relaxant (e.g., atracurim or vecuronium), has the anaesthetic wear off while remaining immobilized due to the continuing effect of only the muscle relaxant. Such circumstance has been known to be highly unpleasant due to the patient&#39;s inability to reveal that the patient is experiencing the full effect of surgical manipulations. The LMA monitoring system may be useful as a guard against such an event, in view of the more limited effect of some muscle relaxants upon pharyngeal constrictor muscles, which the LMA cuff  19  necessarily contacts with its ability to monitor for muscle activity. Others have observed that the contraction curve of the pharyngeal constrictor muscles is unchanged during partial paralysis caused by a common muscle relaxant. See, Ericsson, et al.,  Functional Assessment of the Pharynx at Rest and during Swallowing in Partially paralyzed Humans ; Anaesthesiology, V 87, No. 5, November 1997. 
   12. It is noted further that although the monitoring and other detecting functions of the described system are preferably in the context of LMA inflation response, the LMA context is merely illustrative of use of a suitable inflated device within the pharyngeal cavity to respond to and produce appropriate warning of the muscle action in the region of inflated-material contact with one or more regions of muscle action. 
   13. And it is also noted further that preferred numerical values stated herein as 4, 8, 32, etc. are only illustrative and that they have been selected as power values of 2, in view of the preferred reliance on digital-system operation.