Comparison of laryngeal mask airway (LMA)-Proseal™ and the LMA-Classic™ in ventilated children receiving neuromuscular blockade

A Comparative Study of the ProSeal Laryngeal Mask Airway Versus Endotracheal Tube in Neonates With Anorectal Malformations

BACKGROUND

Laryngeal mask airways (LMAs) are widely used in paediatric anaesthesia. However, LMA use in neonatal age groups (younger than seven days) is limited because many anaesthesiologists prefer to use endotracheal tube in neonates. In this study, we compared the ProSeal LMA and endotracheal tube by measuring their performance, including ease of insertion via number of attempts for placement of device, total effective time for intubation and extubation, hemodynamic responses and perioperative complications.

METHODS

In this prospective randomized study, 70 patients (neonates) weighing >2.5 kg, with American Society of Anaesthesiologists (ASA) classification grade 4 requiring emergency surgery for anorectal malformation were enrolled and divided into two groups. After induction, patients' airways were secured with either ProSeal LMA size 1 (Group I) or endotracheal tube (Group II). Anaesthesia was maintained on oxygen and sevoflurane with muscle relaxant atracurium.

RESULTS

Demographic and surgical data were similar between the two groups. The ProSeal LMA insertion time was shorter than endotracheal intubation. Hemodynamic variations were less in the ProSeal LMA group as compared to the endotracheal tube group. The total time for removal of airway devices from the end of surgery for the ProSeal group was lower than that for the endotracheal intubation group. Postoperative complications were less in the ProSeal group as compared to the endotracheal group.

CONCLUSIONS

The ProSeal LMA can be a better alternative to the endotracheal tube in neonates due to the ease of insertion, lesser changes in hemodynamic parameters and minimal postoperative complications.

The design of the perfect pediatric supraglottic airway device

The design evolution of the pediatric supraglottic airway device has experienced a long and productive journey. We have a wealth of clinical studies to support progress and advancements in pediatric clinical practice. While all of the  supraglottic airway devices have been used successfully in millions of children, it is important to be aware of design advantages and disadvantages of the different models of  supraglottic airway devices. Current pediatric supraglottic airway devices may be improved in design to be more ideal. Industry-changing technological advancements are likely to occur in the near future, which may further improve clinical performance of these devices.

Self-pressurized air-Q® intubating laryngeal airway versus the LMA® Classic™: a randomized clinical trial

PURPOSE

The self-pressurized air-Q® (air-Q SP) intubating laryngeal airway is a relatively new supraglottic airway (SGA) device. The intracuff pressure of air-Q dynamically equilibrates with the airway pressure and adjusts to the patient's pharyngeal and periglottic anatomy, potentially providing improved airway fit and seal. The aim of this prospective randomized study was to compare the clinical performance of air-Q to the LMA® Classic™ SGA.

METHODS

Adult patients requiring general anesthesia for elective surgery were prospectively enrolled and randomly assigned to either air-Q SP or the LMA Classic SGA. Oropharyngeal leak pressure (primary endpoint), success rate, insertion features (insertion time, ease of insertion, requirement for device manipulation), sealing function, gastric insufflation, bronchoscopic view, and oropharyngeal complications at device insertion and following its removal (sore throat, dysphagia, dysphonia) were compared.

RESULTS

The mean (standard deviation [SD]) oropharyngeal leak pressure just after insertion was similar in the air-Q SP and LMA [16.8 (4.9) vs 18.6 (5.5) cm H₂O, respectively; mean difference, 1.8 cm H₂O; 95% CI, -0.5 to 4.2; P = 0.13] and did not differ at ten minutes following device insertion. Median [interquartile range (IQR)] peak inspiratory pressure just after insertion was lower in the air-Q SP (11.0 [10.0-13.0] vs 13.0 [11.0-14.0] cmH₂O, median difference, 1.0 cm H₂O; 95% CI, 0.0 to 2.0; P = 0.03) but no difference was observed at ten minutes. The median [IQR] insertion time was faster with the air-Q SP (15.9 [13.6-20.3] sec vs 24 [21.2-27.1] sec; median difference, 8.1 sec; 95% CI, 5.6 to 9.9; P < 0.001) and improved bronchoscopic viewing grade were seen with the air-Q SP immediately after insertion (P < 0.001). No differences between the groups were observed with respect to the rate of successful insertion at first attempt, overall insertion success rate, ease of insertion, and complications.

CONCLUSIONS

The air-Q SP had similar leak pressures but a faster insertion time and superior bronchoscopic viewing grade when compared with the LMA Classic. The air-Q SP is a suitable alternative to the LMA Classic in adult patients and may be a superior conduit for tracheal intubation.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT02206438). Registered 1 August 2014.

Comparison of the Laryngeal Mask Airways: Laryngeal Mask Airway-classic and Laryngeal Mask Airway-proseal in Children

Introduction:

In the past 25 years with the development of various supraglottic airway devices, the armamentarium for airway management has increased. In our study, the laryngeal mask airway (LMA)-ProSeal is compared with the LMA-Classic with respect to as follows: (a) Ease of insertion and number of insertion attempts, (b) Device positional stability and possible oropharyngeal leak, (c) Airway trauma, and (d) Hemodynamic changes; in children aged 3–15 years undergoing elective surgery under general anesthesia, hypothesizing that these would be different.

Materials and Methods:

Sixty consecutive American Society of Anesthesiologists Physical Status Classes I and II children aged 3–15 years and weighing 5–45 kg undergoing elective surgery in the supine position were randomized for airway management with the LMA-Classic or LMA-ProSeal.

Results:

Size of the LMA used in both LMA-Classic and LMA-ProSeal was 1.5, 2, and 2.5 and was statistically nonsignificant. There was no difference between LMA-Classic and LMA-ProSeal with regard to ease of insertion, number of attempts for insertion, device positional stability, airway trauma and hemodynamic changes.

Conclusions:

The complications of usage of the LMA are minimal and similar in both the devices. The LMA-ProSeal has advantages over LMA-classic such as the placement of gastric tube, adequate ventilation, and oxygenation without any gastric distension.

A network meta-analysis of the clinical properties of various types of supraglottic airway device in children

We conducted both conventional pairwise and Bayesian network meta-analyses to compare the clinical properties of supraglottic airway devices in children. We searched six databases for randomised clinical trials. Our primary end-points were oropharyngeal leak pressure, risk of insertion failure at first attempt, and blood staining risk. The risk of device failure, defined as the abandonment of the supraglottic airway device and replacement with a tracheal tube or another device, was also analysed. Sixty-five randomised clinical trials with 5823 participants were identified, involving 16 types of supraglottic airway device. Network meta-analysis showed that the i-gel™, Cobra perilaryngeal airway™ and Proseal laryngeal mask airway (LMA^® -Proseal) showed statistically significant differences in oropharyngeal leak pressure compared with the LMA^® -Classic, with mean differences (95% credible interval, CrI) of 3.6 (1.9-5.8), 4.6 (1.7-7.6) and 3.4 (2.0-4.8) cmH₂ O, respectively. The i-gel was the only device that significantly reduced the risk of blood staining of the device compared with the LMA-Classic, with an odds ratio (95%CrI) of 0.46 (0.22-0.90). The risk (95%CI) of device failure with the LMA-Classic, LMA^® -Unique and LMA-Proseal was 0.36% (0.14-0.92%), 0.49% (0.13-1.8%) and 0.50% (0.23-1.1%), respectively, whereas the risk (95%CI) of the i-gel and PRO-Breathe was higher, at 3.4% (2.5-4.7%) and 6.0% (2.8-12.5%), respectively. The risk, expressed as odds ratio (95%CrI), of insertion failure at first attempt, was higher in patients weighing < 10 kg at 5.1 (1.6-20.1). We conclude that the LMA-Proseal may be the best supraglottic airway device for children as it has a high oropharyngeal leak pressure and a low risk of insertion. Although the i-gel has a high oropharyngeal leak pressure and low risk of blood staining of the device, the risk of device failure should be evaluated before its routine use can be recommended.

Comparing the Laryngeal Mask Airway, Cobra Perilaryngeal Airway and Face Mask in Children Airway Management

OBJECTIVE

We compared the effects of the laryngeal mask airway (LMA), face mask and Cobra perilaryngeal airway (PLA) in the airway management of spontaneously breathing paediatric patients undergoing elective inguinal surgery.

METHODS

In this study, 90 cases of 1-14-year-old children undergoing elective inguinal surgery were scheduled. The patients were randomly divided into three groups. Anaesthesia was provided with sevoflurane and 50%-50% nitrous oxide and oxygen. After providing an adequate depth of anaesthesia, supraglottic airway devices were inserted in the group I and II patients. The duration and number of insertion, haemodynamic parameters, plateau and peak inspiratory pressure and positive end-expiratory pressure of the patients were recorded preoperatively, after induction and at 5, 10, 15 and 30 min peroperatively.

RESULTS

There were no statistical differences between the groups in terms of haemodynamic parameters (p>0.05). In group II, instrumentation success was higher and instrumentation time was shorter than group II. The positive end-expiratory pressure and plateau and peak inspiratory pressure values were statistically lower in group II (p<0.05).

CONCLUSION

We concluded that for airway safety and to avoid possible complications, LMA and Cobra PLA could be alternatives to face mask and that the Cobra PLA provided lower airway pressure and had a faster and more easy placement than LMA.

A prospective study to evaluate and compare laryngeal mask airway ProSeal and i-gel airway in the prone position

Background:

Prone position is commonly used to provide surgical access to a variety of surgeries. In view of the advantages of induction of anesthesia in the prone position, we conducted a randomized study to evaluate and compare ProSeal laryngeal mask airway (LMA) and i-gel in the prone position.

Materials and Methods:

Totally, 40 patients of either sex as per American Society of Anesthesiologists physical status I or II, between 16 and 60 years of age, scheduled to undergo surgery in prone position were included in the study. After the patients positioned themselves prone on the operating table, anesthesia was induced by the standard technique. LMA ProSeal was used as an airway conduit in group 1 while i-gel was used in group 2. At the end of surgery, the airway device was removed in the same position.

Results:

Insertion of airway device was successful in first attempt in 16, and 17 cases in ProSeal laryngeal mask airway (PLMA) and i-gel groups, respectively. A second attempt was required to secure the airway in 4 and 3 patients in PLMA and i-gel groups, respectively. The mean insertion time was 21.8 ± 2.70 s for group 1 and 13.1 ± 2.24 s for group 2, the difference being statistically significant (P < 0.05). The mean seal pressure in group 1 was 36 ± 6.22 cm H₂ O and in group 2 was 25.4 ± 3.21 cm H₂ O. The difference was statistically significant (P < 0.05). 13 patients in group 1 had fiberoptic bronchoscopy (FOB) grade 1 while it was 6 for group 2. The remaining patients in both groups had FOB grade 2.

Conclusion:

Insertion of supraglottic airways and conduct of anesthesia with them is feasible in the prone position. The PLMA has a better seal while insertion is easier with i-gel.

Comparison of ProSeal laryngeal mask airway size 2 and 2½ in anesthetized and paralyzed pediatric patients with same weight group: A prospective randomized clinical study

Context:

ProSeal laryngeal mask airway (PLMA) efficacy in pediatric anesthesia.

Aims:

The aim of this study was to compare PLMA size 2 and 2½ in anesthetized paralyzed pediatric patients weighing 20–30 kg undergoing elective surgery.

Settings and Design:

A prospective randomized study was conducted in a tertiary care teaching hospital.

Materials and Methods:

A total of 60 American Society of Anesthesiologists I pediatric patients of either sex having body weight between 20 and 30 kg undergoing elective surgeries were randomly allocated to PLMA of either size 2 or 2½. Standardized anesthetic technique with propofol, sevoflurane, vecuronium bromide, nitrous oxide was used in all patients. Parameters such as number of attempts, time to achieve an effective airway, hemodynamic parameters, drain tube test, oropharyngeal leak pressure (OPL), gastric tube placement, and postoperative adverse events were noted. Statistical analysis by Kolmogorov-Smirnov analysis, Mann-Whitney U-test, Student's t-test, Wilk's lambda test and power analysis was done.

Results:

There were no significant differences in demographic variables, ease of insertion and ventilation, number of insertion attempts, hemodynamics, and postoperative complications. OPLs were slightly higher in PLMA size 2½ (27.38 ± 6.36 vs. 22.62 ± 2.85 cm H₂O, respectively; P = 0.001) than size 2.

Conclusions:

Both PLMA size 2 and 2½ provided adequate seal pressures that would allow positive pressure ventilation in healthy children. Thus PLMA of either size 2 or 2½ can be used as a reliable airway device in children weighing 20-30 kg.

Development of a guideline for the management of the unanticipated difficult airway in pediatric practice

BACKGROUND

Most airway problems in children are identified in advance; however, unanticipated difficulties can arise and may result in serious complications. Training for these sporadic events can be difficult. We identified the need for a structured guideline to improve clinical decision making in the acute situation and also to provide a guide for teaching.

OBJECTIVE

Guidelines for airway management in adults are widely used; however, none have been previously devised for national use in children. We aimed to develop guidelines for the management of the unanticipated difficult pediatric airway for use by anesthetists working in the nonspecialist pediatric setting.

METHOD

We reviewed available guidelines used in individual hospitals. We also reviewed research into airway management in children and graded papers for the level of evidence according to agreed criteria. A Delphi panel comprising 27 independent consultant anesthetists considered the steps of the acute airway management guidelines to reach consensus on the best interventions to use and the order in which to use them. If following the literature review and Delphi feedback, there was insufficient evidence or lack of consensus, regarding inclusion of a particular point; this was reviewed by a Second Specialist Group comprising 10 pediatric anesthetists.

RESULTS

Using the Delphi group's deliberations and feedback from the Second Specialist Group, we developed three guidelines for the acute airway management of children aged 1-8 years.

CONCLUSIONS

This paper provides the background, available evidence base, and justification for each step in the resultant guidelines and gives a rationale for their use.

An update on newer pediatric supraglottic airways with recommendations for clinical use

Supraglottic airways are an established part of routine and emergency pediatric airway management, including use in difficult airways and neonatal resuscitation. With the introduction of newer supraglottic airways in children, efficacy can only be determined by comparing these devices with those that are already well established (laryngeal mask airway Classic and laryngeal mask airway ProSeal). This narrative review aims to present the current literature on these newer supraglottic airways and give recommendations for their use in various clinical scenarios based on the existing evidence.

Are new supraglottic airway devices, tracheal tubes and airway viewing devices cost-effective?

Over the past two decades, a plethora of new airway devices has become available to the pediatric anesthetist. While all have the laudable intention of improving patient care and some have proven clinical benefits, these devices are often costly and at times claims of an advantage over current equipment and techniques are marginal. Supraglottic airway devices are used in the majority of pediatric anesthetics delivered in the U.K., and airway-viewing devices provide an alternative for routine intubation as well as an option in the management of the difficult airway. Yet hidden beneath the convenience of the former and the technology of the latter, the impact on basic airway skills with a facemask and the lack of opportunities to fine-tune the core skill of intubation represent an unrecognised and unquantifiable cost. A judgement on this value must be factored into the absolute purchase cost and any potential benefits to the quality of patient care, thus blurring any judgement on cost-effectiveness that we might have. An overall value on cost-effectiveness though not in strict monetary terms can then be ascribed. In this review, we evaluate the role of these devices in the care of the pediatric patient and attempt to balance the advantages they offer against the cost they incur, both financial and environmental, and in any quality improvement they might offer in clinical care.

Comparison of Size 2 LMA-ProSeal™ and LMA-Supreme™ in Spontaneously Breathing Children: a Randomised Clinical Trial

OBJECTIVE

The aim of this study was to compare size 2 Laryngeal Mask Airway ProSeal and size 2 Laryngeal Mask Airway Supreme in spontaneously breathing children undergoing lower abdominal elective surgery of <1 hour duration.

STUDY DESIGN

Randomized clinical trial.

MATERIAL AND METHODS

Sixty children aged 1-7 years, weighing 10-20 kg, ASA I physical status were randomly allocated to the Laryngeal Mask Airway ProSeal and Laryngeal Mask Airway Supreme.

RESULTS

There were no differences in demographic variables, ease of gastric tube placement, ease of insertion and ventilation, number of insertion attempts, hemodynamic changes on insertion, postoperative complications and bloodstaining between the groups. Gastric insufflation was detected and gastric tube was placed in all patients except one in LMA Supreme. Postoperative cuff volumes were comparable with the preoperative values in group itself. Oropharyngeal leak pressures were higher in Laryngeal Mask Airway ProSeal (24.6±5.5 vs 21.3±4.2, respectively; p<0.01).

CONCLUSION

As a result Laryngeal Mask Airway ProSeal and Laryngeal Mask Airway Supreme can safely be used in spontaneously breathing pediatric population undergoing lower abdominal elective surgery.

A cohort evaluation of the laryngeal mask airway-Supreme™ in children

OBJECTIVES

To assess the clinical performance of the laryngeal mask airway-Supreme in children.

AIM

The purpose of this prospective audit was to evaluate the feasibility of the laryngeal mask airway-Supreme in clinical practice and generate data for future comparison trials.

BACKGROUND

The laryngeal mask airway-Supreme is a new second-generation supraglottic airway that was recently released in limited pediatric sizes (sizes 1, 2).

METHODS

One hundred children, ASA I-III, newborn to 16 years of age, and undergoing various procedures requiring a size 1, 2, or 3 laryngeal mask airway-Supreme were studied. Assessments included insertion success rates, airway leak pressures, success of gastric tube insertion, quality of airway, and perioperative complications.

RESULTS

The first-time insertion success rate was 97%, with an overall insertion success rate of 100%. The mean initial airway leak pressure for all patients was 22.3 ± 6.6 cm H(2) O. Gastric tube placement was possible in 98% of patients. Complications were noted in six patients: coughing or laryngospasm (n = 3), sore throat (n = 1), and dysphonia (n = 2).

CONCLUSIONS

The laryngeal mask airway-Supreme was inserted with a high degree of success on the first attempt by clinicians with limited prior experience with the device. It was effectively used for a variety of procedures in children undergoing spontaneous and mechanical ventilation with minimal complications. The leak pressures demonstrated in this study, along with access for gastric decompression, suggest that the laryngeal mask airway-Supreme may be an effective device for positive pressure ventilation in children.

A simple method of partial inflation of the LMA cuff before insertion in children to allow cuff pressure without adjustment after insertion

Background

The cuff of the laryngeal mask airway (LMA) is preferred to be partially inflated before insertion in pediatric cases. However, it is not known how much inflation is appropriate. In addition, intra-cuff pressure is not routinely monitored in many institutions despite the fact that a neglected high cuff pressure could cause several complications. This study was conducted to determine whether the cuff inflated with its resting volume before insertion could have a clinically tolerable intra-cuff pressure after insertion.

Methods

One hundred fifty unpremedicated children aged 0 to 9 yrs were enrolled. The pilot balloon valve was connected to a piston-free syringe to keep the valve open to the atmosphere and allowing the pressure within the cuff of to LMA to equalize to atmospheric pressure. Anesthesia was induced with 6 vol% of sevoflurane in oxygen. After insertion and final positioning of the LMA, the intra-cuff pressure was measured using a cuff pressure manometer.

Results

The mean intra-cuff pressure was 50 ± 12.9 cmH₂O; intra-cuff pressures were 39.1 ± 9.3, 51.6 ± 11.2, and 64.6 ± 12.5 cmH₂O for LMAs of sizes 1.5, 2, and 2.5, respectively. Intra-cuff pressure of more than 60 cmH₂O was measured in 26 patients, and the median value was 70 cmH₂O. There was weak statistical correlation among age, height, and weight with intra-cuff pressure.

Conclusions

The cuff inflated by the resting volume before insertion may be a simple method for guaranteeing tolerable cuff pressure after insertion.

Initial experience of the i-gel supraglottic airway by the residents in pediatric patients

PURPOSE

Insertion of a laryngeal mask airway (LMA) is occasionally difficult in children because of their anatomical features and variations. A new single-use supraglottic airway device, the i-gel airway, was recently introduced. The objective of this study was to show the initial experience of the i-gel airway device by the residents for pediatric patients.

METHODS

With approval from the local ethics committee and parental informed consent, 70 children undergoing minor surgery in the supine position, ASA score I-II, were investigated. Exclusion included patients having thoracic, neurosurgical, spine, and otolaryngological procedures. Patients were divided into three groups: group 1 was airway size 1.5 for patients weighing 5-12 kg, group 2 was size 2 for 10-25 kg, and group 3 was size 2.5 for those weighing 25-35 kg. The following seven characteristics were evaluated: (1) ease of the i-gel and gastric tube insertion; (2) leak pressure; (3) tidal volume/body weight at leak pressure point; (4) fiberscope score; (5) insertion time; (6) hypoxia rate (laryngospasm); and (7) coughing and trace of bleeding.

RESULTS

The overall insertion success rate and the success rate at first attempt were 99% and 94%, respectively. Gastric tube insertions were easy in all patients. The overall leak pressure was 23 ± 5 cmH(2)O. The tidal volume per body weight was 24 ± 10 ml/kg. A good view of the fiberscope was achieved in 79%. In group 1 (size 1.5), one failed insertion, two dislocations, and one dysphonia were observed. Hypoxia rate was 1%. There was no case with coughing and trace of bleeding.

CONCLUSION

These results show that the i-gel airway is a safe and effective device for use by residents who do not have experience with insertion of a pediatric LMA. However, using size 1.5, special caution should be taken to protect the infant airway, similar to what has been previously reported for other airway devices.

A randomized crossover comparison between the Laryngeal Mask Airway-Unique™ and the air-Q intubating laryngeal airway in children

OBJECTIVES

The purpose of this randomized crossover study was to evaluate the feasibility of the air-Q intubating laryngeal airway (ILA) in clinical practice when compared with the Laryngeal Mask Airway-Unique(™) (LMA-U), the current standard of care for primary airway maintenance.

AIM

We hypothesized that the ILA would have better airway seal pressures and laryngeal alignment than the LMA-U in anesthetized nonparalyzed children.

BACKGROUND

The ILA is a newer supraglottic airway for children with design features that allow it to be used for primary airway maintenance and as a conduit for tracheal intubations.

METHODS

Fifty healthy children, 6-36 months of age, 10-15 kg, who were scheduled for elective surgery in which the use of a size two LMA-U and size 1.5 ILA would be appropriate for airway maintenance, were enrolled into this randomized crossover study. Primary outcome measures were airway leak pressures and fiberoptic grades of view. Secondary outcome measures included ease and time for successful insertion, incidence of gastric insufflation, ventilation parameters, and complications.

RESULTS

There were no statistically significant differences in regard to the ease of device insertion, time to ventilation, gastric insufflation, and ventilation parameters between the ILA and the LMA-U. All devices were successfully placed on the first attempt, and there were no instances of failure. There were statistically significant differences in the airway leak pressure between the ILA (19.0 ± 5.4 cmH(2)O) and the LMA-U (16.1 ± 4.9 cmH(2)O), P = 0.001. There were also statistically significant differences in the fiberoptic grades of view between the ILA and LMA-U, P = 0.004.

CONCLUSIONS

The ILA had higher airway leak pressures and superior fiberoptic grades of view when compared with the LMA-U and can be a suitable alternative to the LMA-U in children weighing 10-15 kg.

Size 2.5 ProSeal(™) LMA: Is it associated with increased attempts at insertion?

BACKGROUND

This randomized controlled study evaluated the success rate of insertion and the associated oropharyngeal morbidity for sizes 1.5,2 and 2.5 of ProSeal(™) laryngeal mask airway (PLMA) using an alternative digital technique (D) with conventional technique using the introducer tool (IT) technique.

METHODS

After approval from the hospital ethics committee, 250 healthy children, 6-months to 10 years of age, undergoing elective sub-umbilical surgeries, were included and randomly allocated to D and IT groups for PLMA insertion. The standard anaesthesia protocol was followed. The primary outcomes were success rate of insertion at first attempt and blood on device on removal and the secondary outcomes were oropharyngeal leak pressure and gastric tube placement.

RESULTS

The success rate of PLMA insertion at first attempt for sizes 1.5 and 2 did not differ between the two groups. However, for size 2.5, it was significantly lower than that for the other two sizes in both groups. The incidence of blood on device was higher with the 2.5 airway in both groups, reaching statistical significance only in group D. Other parameters did not differ between the two groups.

CONCLUSION

We conclude that size 2.5 PLMA is associated with a lower success rate of insertion and a higher incidence of blood on device using both techniques. Insertion of PLMA sizes 1.5 and 2 by an alternative digital technique is comparable to the IT technique.

The effect of head rotation on efficiency of ventilation and cuff pressure using the PLMA in pediatric patients

Background

This study examined whether changing the head position from neutral to side can affect expiratory tidal volume (TV) and cuff pressure when the appropriate sizes of a Proseal™ Laryngeal Mask Airway (PLMA)-depending on the body weight -are used in pediatric patients during pressure controlled ventilation (PCV).

Methods

Seventy-seven children (5-30 kg) were divided into three groups according to their body weight, PLMA#1.5 (group I, n = 24), #2 (group II, n = 26), and #2.5 (group III, n = 27). After anesthesia induction, a PLMA was placed with a cuff-pressure of 60 cmH₂O. The TV and existence of leakage at the peak inspiratory pressure (PIP) of 20 cmH₂O, and the appropriate PIP for TV 10 ml/kg were examined. Upon head rotation to the left side, the TV, PIP, cuff pressure changes, and the appropriate PIP to achieve a TV 10 ml/kg were evaluated.

Results

Head rotation of 45 degrees to the left side during PCV caused a significant increase in cuff pressure and a decrease in TV, and there was no definite leakage. Changes in PIP and TV were similar in the three groups. The cuff pressure increased but there was no significant difference between the three groups.

Conclusions

Although cuff pressure and TV of the PLMA were changed significantly after turning the head from the neutral position to the side, a re-adjustment of the cuff pressure and PIP to maintain a TV of 10 ml/kg can make the placed PLMA useful and successful in pediatric patients under general anesthesia.

Prospective evaluation of the self-pressurized air-Q intubating laryngeal airway in children

OBJECTIVES

To assess the clinical efficacy of the self-pressurized air-Q ILA™ (ILA-SP).

AIM

  The purpose of this prospective audit was to evaluate the feasibility of the ILA-SP in clinical practice and generate data for future comparison trials.

BACKGROUND

The ILA-SP is a new first-generation supraglottic airway for children with a self-adjusting cuff and lack of a pilot balloon.

METHODS

Over a 4-month period, 352 children with an ASA physical status of I-III, newborn to 18 years of age, undergoing various procedures were studied. Data points assessed included insertion success rates, airway leak pressures, quality of ventilation, and perioperative complications associated with the use of this device.

RESULTS

In 349 of the 352 patients in this study, the ILA-SP was used successfully as a primary supraglottic airway device in a variety of patients. Three patients required conversion to a standard laryngeal mask airway or a tracheal tube. The mean initial airway leak pressure for all patients was 17.8 ± 5.4 cm H(2)O, and 20.4 ± 5.5 cm H(2)O when re-checked at 10 min, which was statistically significant (P < 0.001). Complications were limited to 14 patients and related to reflex activation of the airway (coughing, laryngospasm, and bronchospasm) (n = 10), sore throat (n = 3), and blood staining on removal of the device (n = 1). There were no episodes of regurgitation, aspiration, or hoarseness.

CONCLUSIONS

Acceptable clinical performance was demonstrated with the ILA-SP for a variety of procedures in infants and children with spontaneous and positive pressure ventilation. Future studies comparing this device to other supraglottic airways may provide useful information regarding the safety of the ILA-SP in pediatric clinical practice.

Crossover comparison of airway sealing pressures of 1.5 and 2 size LMA-ProSeal™ and LMA-Classic™ in children, measured with the manometric stability test

OBJECTIVES

To compare airway sealing pressures, air leak, optimal positioning of the LMA-ProSeal™ and LMA-Classic™ in children.

METHODS

A crossover, randomized study was conducted in children aged 6 months-7 years weighing <20 kg scheduled for minor elective surgery under GA with sevoflurane. Either a 1.5 or 2-size LMA-ProSeal™ or LMA-Classic™ was inserted first. Optimal position of the devices was evaluated by fiberoptic bronchoscopy (FOB). Airway sealing pressures were determined under standardized conditions by the manometric stability test at the proximal end of the LMA device. Gas leak observed by auscultation over the neck and epigastrium was noted at these pressures.

RESULTS

Twenty-seven children of mean ages 29.48 ± 19.81 months and mean weight 11.23 ± 3.28 kg were included for evaluation. Airway sealing pressures were noted to be similar: 23.11 ± 8.28 cm H(2)O with LMA-ProSeal™ and 23.26 ± 8.21 cm H(2)O with LMA-Classic™. At these sealing pressures, air leak in the neck was observed in 21/27 children with LMA-ProSeal™ compared with 24/27 with LMA-Classic™ (P = 0.467). Optimal device positioning as viewed by FOB was seen in 14/27(51.8%) children with LMA-ProSeal™ and 15/27(55.6%) with LMA-Classic™. Airway sealing pressures with suboptimal position of LMA-ProSeal™ was 22.23 ± 10.23 cm H(2)O and with optimal position 23.93 ± 6.25 cm H(2)O (P = 0.612).

CONCLUSION

The LMA-ProSeal™ and LMA-Classic™ size 1.5 and 2 provide similar mean airway sealing pressures as assessed by the manometric stability test under standardized conditions, with similar air leak and optimal positioning.

A clinical evaluation of the intubating laryngeal airway as a conduit for tracheal intubation in children

BACKGROUND

The air-Q Intubating Laryngeal Airway (ILA) (Cookgas LLC, Mercury Medical, Clearwater, FL) is a supraglottic airway device available in pediatric sizes, with design features to facilitate passage of cuffed tracheal tubes when used to guide tracheal intubation. We designed this prospective observational study of the ILA to assess the ease of its placement in paralyzed pediatric patients, determine its position and alignment to the larynx using a fiberoptic bronchoscope, gauge its efficacy as a conduit for fiberoptic intubation with cuffed tracheal tubes, and evaluate the ability to remove the ILA without dislodgement of the tracheal tube after successful tracheal intubation.

METHODS

One hundred healthy children, aged 6 months to 8 years, ASA physical status I to II, and scheduled for elective surgery requiring general endotracheal anesthesia were enrolled in this prospective study. Based on the manufacturer's guidelines, each patient received either a size 1.5 or 2.0 ILA according to their weight. The number of attempts for successful insertion, leak pressures, fiberoptic grade of view, number of attempts and time for tracheal intubation, time for ILA removal, and complications were recorded.

RESULTS

ILA placement, fiberoptic tracheal intubation, and ILA removal were successful in all patients. The size 1.5 ILA cohort had significantly higher rates of epiglottic downfolding compared with the size 2.0 ILA cohort (P < 0.001), despite adequate ventilation variables. When comparing fiberoptic grade of view to weight, a moderate negative correlation was found (r = -0.41, P < 0.001), indicating that larger patients tended to have better fiberoptic grades of view. The size 1.5 ILA cohort had a significantly longer time to intubation (P = 0.04) compared with the size 2.0 ILA cohort. However, this difference may not be clinically significant because there was a large overlap of confidence bounds in the average times of the size 1.5 ILA (27.0 ± 13.0 seconds) and size 2.0 ILA cohorts (22.7 ± 6.9 seconds). When comparing weight to time to tracheal intubation, a weak correlation that was not statistically significant was found (r = -0.17, P = 0.09), showing that time to intubation did not differ significantly according to weight, despite higher fiberoptic grades in smaller patients.

CONCLUSIONS

The ILA was easy to place and provided an effective conduit for tracheal intubation with cuffed tracheal tubes in children with normal airways. Additionally, removal of the ILA after successful intubation could be achieved quickly and without dislodgement of the tracheal tube. Because of the higher incidence of epiglottic downfolding in smaller patients, the use of fiberoptic bronchoscopy is recommended to assist with tracheal intubation through this device.

ProSeal laryngeal mask airway: An alternative to endotracheal intubation in paediatric patients for short duration surgical procedures

The laryngeal mask airway (LMA) is a supraglottic airway management device. The LMA is preferred for airway management in paediatric patients for short duration surgical procedures. The recently introduced ProSeal (PLMA), a modification of Classic LMA, has a gastric drainage tube placed lateral to main airway tube which allows the regurgitated gastric contents to bypass the glottis and prevents the pulmonary aspiration. This study was done to compare the efficacy of ProSeal LMA with an endotracheal tube in paediatric patients with respect to number of attempts for placement of devices, haemodynamic responses and perioperative respiratory complications. Sixty children, ASA I and II, weighing 10-20 kg between 2 and 8 years of age group of either sex undergoing elective ophthalmological and lower abdominal surgeries of 30-60 min duration, randomly divided into two groups of 30 patients each were studied. The number of attempts for endotracheal intubation was less than the placement of PLMA. Haemodynamic responses were significantly higher (P<0.05) after endotracheal intubation as compared to the placement of PLMA. There were no significant differences in mean SpO(2) (%) and EtCO(2) levels recorded at different time intervals between the two groups. The incidence of post-operative respiratory complications cough and bronchospasm was higher after extubation than after removal of PLMA. The incidence of soft tissue trauma was noted to be higher for PLMA after its removal. There were no incidences of aspiration and hoarseness/sore throat in either group. It is concluded that ProSeal LMA can be safely considered as a suitable and effective alternative to endotracheal intubation in paediatric patients for short duration surgical procedures.

Audit of performance of size 1.5 ProSeal laryngeal mask airways in infants less than six months undergoing inguinal herniotomy

Many anaesthetists have found the size 1.5 classic Laryngeal Mask Airway unsuitable for use in children under 10 kg, whereas recent studies evaluating the ProSeal Laryngeal Mask Airway (PLMA) show high success rates, even during laparoscopic surgery. Our routine practice has been to use tracheal intubation for inguinal herniotomy in children weighing less than 10 kg. Following the introduction of the PLMA to our hospital, we decided to audit our use of the PLMA 1.5 in this group of patients. We included 20 consecutive infants, aged less than six months and weighing 5 to 10 kg. We recorded patient, anaesthetic and insertion details, device performance data and complications. No aspect of anaesthetic practice was changed by involvement in this audit. The PLMA was inserted successfully at the first attempt in 85% (17/20) of infants. Overall successful insertion occurred in 90% (18/20) and satisfactory airway maintenance was provided for the duration of anaesthesia in 90% (18/20). The mean leak pressure was 24 cmH2O (range 15 to 30 cmH2O). We found the 1.5 PLMA provided a satisfactory airway in 90% of infants. This report adds to the evidence that the PLMA 1.5 can provide a satisfactory alternative to intubation in selected infants.

A critique of elective pediatric supraglottic airway devices

In 1988, when the Laryngeal Mask Airway-Classic (Intavent Orthofix, Maidenhead, UK), was introduced there were only two choices of airway management: tracheal tube or facemask. The supraglottic airway, as we now understand the term, did not exist. Yet, 20 years later, we are faced with an ever increasing choice of supraglottic airway devices (SAD). For many SADs, with the exception of the LMA-Classic and LMA-Proseal (Intavent Orthofix, Maidenhead, UK), there is a lack of high quality data of efficacy. The best evidence requires a randomized controlled trial comparing a new device against an established alternative, properly powered to detect clinically relevant differences in clinically important outcomes. Such studies in children are very rare. Safety data is even harder to establish particularly for rare events such as aspiration. Therefore, most safety data comes from extended use rather than high quality evidence which inevitably biases against newer devices. For reason of these factors, claims of efficacy and particularly safety must be interpreted cautiously. This narrative review aims to present the evidence surrounding the use of currently available pediatric SADs in routine anesthetic practice.

A cohort evaluation of the pediatric ProSeal laryngeal mask airway in 100 children

BACKGROUND

The ProSeal laryngeal mask airway (PLMA) has been available in pediatric sizes in the UK since 2007. Although several non-UK studies have evaluated PLMAs in children, there are little published data regarding their use in this country. Having decided to introduce the pediatric PLMA into our practice, we chose to prospectively audit the first 100 uses as part of our clinical governance.

METHODS

We studied children undergoing elective surgery who were considered suitable for a supraglottic airway. We recorded patient, surgical and insertion details, device performance data and complications. Patient management was not altered by inclusion in this audit.

RESULTS

Twenty size 1.5, 55 size 2.0, 15 size 2.5 and 10 size 3.0 PLMAs were inserted in 100 consecutive children [median age 2 years (range 2 months to 10 years) and median weight 15 kg (range 4.9-60 kg)]. The overall first attempt success rate was 93% (size 1.5, 100%; size 2.0, 100%; size 2.5, 87%; size 3.0, 90%) and overall successful insertion rate was 99%. Median leak pressure was 25 cmH(2)O. Outright failure was seen in one patient; complications were seen in another six patients (partial airway obstruction in five patients and mild laryngospasm in one patient), all of whom were transient and none of whom required intubation. No episodes of regurgitation were recorded.

CONCLUSIONS

Even without prior experience and using nonconventional insertion, pediatric PLMAs (including size 1.5) can be easily inserted and provide an effective airway.