Failure of the Laryngeal Mask Airway Unique™ and Classic™ in the Pediatric Surgical Patient

[Update 2022: interdisciplinary statement on airway management with supraglottic airway devices in pediatric emergency medicine-The laryngeal mask is and remains state of the art : Joint statement of the Institute for Emergency Medicine and Medicine Management (INM), the University Clinic Munich, LMU Munich, Germany, the Working Group for Pediatric Critical Care and Emergency Medicine of the German Interdisciplinary Society for Critical Care and Emergency Medicine (DIVI), the Medical Directors of Emergency Medical Services in Bavaria (ÄLRD), the Scientific Working Group for Pediatric Anesthesia (WAKKA) of the German Society for Anesthesiology and Intensive Care Medicine (DGAI), the Scientific Working Group for Emergency Medicine of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and the Society of Neonatology and Pediatric Critical Care Medicine (GNPI)]

BACKGROUND

Airway management with supraglottic airway devices (SGA) in life-threatening emergencies in children is increasingly being used. Different specifications of laryngeal masks (LM) and the laryngeal tube (LT) are commonly used devices for this purpose. We present a literature review and interdisciplinary consensus statement of different societies on the use of SGA in pediatric emergency medicine.

MATERIAL AND METHODS

Literature review in the PubMed database and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine. Levels and consensus finding within the group of authors.

RESULTS

The evidence for successful applications of the various types of LM is significantly higher than for LT application. Reported smaller series of successful applications of LT are currently limited to selected research groups and centers. Especially for children below 10 kg body weight there currently exists insufficient evidence for the successful application of the LT and therefore its routine use cannot be recommended. SGAs used for emergencies should have a gastric drainage possibility.

DISCUSSION

Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children currently only the LM can be recommended for alternative (i.e., non-intubation) emergency airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1½, 2, 2½, 3) for out of hospital use and in hospital emergency use and all users should regularly be trained in its application.

Efficacy and Safety of Flexible Laryngeal Mask Ventilation in Otologic Surgery: A Retrospective Analysis

Background

Flexible laryngeal mask airways (FLMAs) ventilation have been widely used as airway devices during general anesthesia, especially in otologic surgery. However, the current literature reports that the clinical success and failure rates for FLMA usage are quite different, and there remains a paucity of data regarding factors associated with FLMA failure and complications related to FLMA usage.

Purpose

To evaluate the success and failure rates of FLMA usage in otologic surgery, the factors associated with FLMA failure and complications related to FLMA usage.

Patients and Methods

All patients who underwent otologic surgery, including middle ear and mastoid procedures, under general anesthesia at a large tertiary general hospital from 2015 to 2019 were reviewed. The primary outcome was the FLMA failure rate, defined as any airway event requiring device removal and tracheal intubation, including primary and secondary failure. The secondary outcomes were specific clinical factors, including patient sex, age, weight, American Society of Anesthesiologists (ASA) classification, body mass index (BMI) and duration of surgery, which were analyzed as related risk factors.

Results

Among 5557 patients with planned FLMA use, the final success rate was 98.5%. Sixty-seven percent of the failures occurred during initial introduction of the FLMA, 8% occurred after head and neck rotation, and 25% occurred during the procedures. Two independent clinical factors associated with FLMA failure were male sex and age. Respiratory complications were observed in 0.61% of patients, and the rate of severe nerve and tissue damage associated with FLMA use was 0.05.

Conclusion

This study demonstrates a high success rate of 98.5% for FLMA use in adults undergoing otologic surgery with rare adverse airway events and injuries complications. Two independent risk factors require attention and thorough and accurate management is necessary for every clinician.

LMA® Gastro™: A paediatric experience

The laryngeal mask airway, the LMA® Gastro™ (Teleflex Medical, Athlone, Ireland), is a novel airway device which permits upper gastrointestinal (GI) endoscopy to be performed via a dedicated large calibre oesophageal lumen. It has been validated in adult studies, but to our knowledge, there have been no data published regarding its use in a paediatric population. Following a brief education programme, the LMA Gastro was introduced on a trial basis at our institution and made freely available. Over a four-month period, our pre-existing endoscopy audit framework captured data on a total of 55 patients who had the LMA Gastro device chosen as the primary airway for elective upper GI endoscopy. These data were collected prospectively by the treating anaesthetist and included a range of airway and endoscopy outcomes. Of the 55 patients, the LMA Gastro provided an adequate airway in 52 (94.5%). Forty-six (88.5%) were sited on first attempt, and 50 (96.2%) insertions were rated 'easy' by the anaesthetist. Aside from three insertion failures, there were no airway events. The endoscopy success rate was 100% in the 52 patients who had an LMA Gastro airway successfully inserted. First-pass oesophageal access was achieved in 51 (98%) cases, and 100% of insertions were rated 'easy' by the gastroenterologist. Despite our relative inexperience with it, the device had a high success rate for airway maintenance and oesophageal access in our paediatric patient population. In our institution, the LMA Gastro provided a useful airway option in older children undergoing elective upper GI endoscopy.

Safety, efficacy and airway complications of the flexible laryngeal mask airway in functional endoscopic sinus surgery: A retrospective study of 6661 patients

OBJECTIVES

Although the flexible laryngeal mask airway (FLMA) provides considerable advantages in head and neck procedures, little is known about its safety and efficacy in functional endoscopic sinus surgery (FESS). We conducted a retrospective study to evaluate the success rate of FLMA and relevant airway complications in FESS under general anaesthesia.

METHODS

A retrospective review of consecutive patients who underwent FESS for chronic rhinosinusitis was performed from 2015 to 2019. All patients scheduled for FLMA ventilation were identified. Patient characteristics, length of the surgery, FLMA size, failed FLMA cases requiring endotracheal intubation, immediate adverse airway events and delayed airway injuries were recorded. The primary outcomes included the FLMA success rate, which was defined as primary success after induction and final success after the whole surgical procedure. The secondary outcomes were specific clinical factors associated with FLMA failure and airway complications related to FLMA usage.

RESULTS

Of the 6661 patients included in our study, primary success was achieved in 6572 (98.7%), and final success was achieved in 6512 (97.8%). Failure occurred in 89 patients (1.3%) during induction, in 14 (0.2%) during surgical preparation and in 46 (0.7%) during the intraoperative procedure. All patients with failed FLMA ventilation were successfully switched to endotracheal intubation. Male sex, advanced age, higher American Society of Anesthesiologists grade (ASA) and higher body mass index (BMI) were independent risk factors associated with failed FLMA. Immediate adverse respiratory events were observed in 0.85% of the patients, and delayed airway injuries associated with use of FLMA were observed in 0.07%.

CONCLUSION

This retrospective study demonstrates a high success rate for FLMA (97.8% in 6661 patients undergoing FESS). Adverse airway events and injuries associated with FLMA are rare, but clinicians should remain vigilant so that early diagnosis and prompt treatment can be provided.

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient

PURPOSE

Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient.

SOURCE

Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus.

FINDINGS AND KEY RECOMMENDATIONS

Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.

The Pediatric Difficult Airway: Updates and Innovations

Children have unique characteristics that make them particularly vulnerable to perioperative adverse events. Skilled airway management is a cornerstone of high-quality anesthetic management. The use of hybrid airway techniques is a critical tool for the pediatric anesthesiologist. Point-of-care ultrasonography has an expanding role in airway management, from preoperative assessment of airway pathology and gastric contents to confirmation of tracheal intubation and identification of the cricothyroid membrane. The exciting fields of 3-dimensional printing, artificial intelligence, and machine learning are areas of innovation that will transform pediatric difficult airway management in years to come.

Subcutaneous emphysema as a complication of the use of a laryngeal mask in a child

The use of supraglottic airway devices has been increasing in popularity, mostly due to their high success rate and low complications. However, there is very little information available about the potential and group specific concerns regarding their use in children. We present the first description of a child that developed subcutaneous emphysema after the use of a laryngeal mask. We believe that more awareness to the risk of perioperative adverse events with laryngeal mask insertion in the paediatric population is needed.

Branchio-otic syndrome: An opportunity to reassess the paediatric anaesthetists’ approach to the difficult syndromic airway

Branchio-oto-renal spectrum disorders are rare genetic entities with variable penetrance and concurrently display a wide phenotypic variation. A common issue to syndromic children is a propensity for difficult bag-mask ventilation, intubation or both. Unfortunately, there is no uniformity of this challenge, assessment strategy or management plan. This case with features of branchio-otic syndrome provided the opportunity to examine several aspects of paediatric anaesthetic airway management. The child was booked for branchial cyst removal but appeared to have other features of abnormal branchial cleft development. An outline of the executed anaesthetic plan is presented and discussed. Three different techniques were sequentially tried in this patient before the airway was secured. Various case reports in the literature inconsistently describe easy to very difficult airway management in children with branchio-oto-renal spectrum disorders. Branchial arch dysgenesis is almost always associated with difficult direct laryngoscopy. There is undoubtedly no singular way to ideally manage a child with a difficult airway. Many tools for difficult airways are available. However, despite the improvement of difficult paediatric airway equipment, it would appear that for the anaesthetist the flexible bronchoscope remains an indispensable tool.

A Comparison of the Mallampati evaluation in neutral or extended cervical spine positions: a retrospective observational study of >80 000 patients

BACKGROUND

The Mallampati examination is a standard component of an airway risk assessment. Existing evidence suggests that cervical spine extension improves the predictive power of the Mallampati examination for detecting difficult laryngoscopy and tracheal intubation, but a comparative effectiveness study has not been conducted.

METHODS

The extended Mallampati examination (EMS) was introduced to the standard preoperative airway assessment, in addition to the standard Modified Mallampati examination (MMP). This study compared the accuracy of both Mallampati examinations on the prediction of difficult laryngoscopy, tracheal intubation, and bag mask ventilation. Univariate and adjusted analyses were performed.

RESULTS

80 801 patients with recorded MMP and EMS, and subsequent glottic view obtained during direct laryngoscopy, were examined. There was increased specificity (88.7% cf. 81.9%) but reduced sensitivity (33.3% cf. 45.7%) in the detection of difficult direct laryngoscopy with use of the EMS. The area under the receiver operating characteristic curve of each test performed in combination with other airway predictors for the models predicting difficult laryngoscopy was 0.740 (95% CI 0.731-0.753) for MMP and 0.739 (95% CI 0.729-0.752) for EMS. The area under the receiver operating characteristic curve of each test, performed in combination with other airway predictors for the models predicting difficult intubation was 0.699 (95% CI 0.688-0.711) for MMP and 0.695 (95% CI 0.683-0.707) for EMS.

CONCLUSIONS

This retrospective observational study demonstrates that cervical extension improves the specificity but decreases sensitivity of Mallampati examination. The Mallampati evaluation should be performed with the cervical spine in the neutral position to maximize test sensitivity.

Management of the Difficult Airway in the Pediatric Patient

Loss of airway control in children, if not resolved quickly, will lead to devastating consequences. Successful management of the pediatric difficult airway, both anticipated and unanticipated, is facilitated by preprocedure assessment and preparation. Accessibility of and continued hands-on training with modern airway instruments, familiarization with difficult airway guidelines, and collaboration with multidisciplinary airway teams can aid in the management of the difficult pediatric airway. This review outlines the importance of airway assessment and advanced airway equipment for children. It also discusses difficult airway management techniques and algorithms for the management and rescue of the pediatric difficult airway.

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.

[Interdisciplinary consensus statement on alternative airway management with supraglottic airway devices in pediatric emergency medicine: Laryngeal mask is state of the art]

BACKGROUND

Airway management with supraglottic airway devices (SGA) in life-threatening emergencies involving children is becoming increasingly more important. The laryngeal mask (LM) and the laryngeal tube (LT) are devices commonly used for this purpose. This article presents a literature review and consensus statement by various societies on the use of SGA in pediatric emergency medicine.

MATERIAL AND METHODS

Literature search in the database PubMed and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine levels of evidence.

RESULTS

The evidence for successful application of the various types of LM is significantly higher than for LT application. Reports of smaller series of successful applications of LT are currently limited to selected research groups and centers. Insufficient evidence currently exists for the successful application of the LT especially for children below 10 kg body weight and, therefore, its routine use cannot currently be recommended. SGAs used for emergencies should have a possibility for gastric drainage.

DISCUSSION

Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children, currently only the LM can be recommended for alternative (i.e. non-intubation) airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1.5, 2, 2.5, 3, 4 and 5) for prehospital and in-hospital emergency use and all users should be regularly trained in its application.

Time Trends and Predictors of Abnormal Postoperative Body Temperature in Infants Transported to the Intensive Care Unit

Background. Despite increasing adoption of active warming methods over the recent years, little is known about the effectiveness of these interventions on the occurrence of abnormal postoperative temperatures in sick infants. Methods. Preoperative and postoperative temperature readings, patient characteristics, and procedural factors of critically ill infants at a single institution were retrieved retrospectively from June 2006 until May 2014. The primary endpoints were the incidence and trend of postoperative hypothermia and hyperthermia on arrival at the intensive care units. Univariate and adjusted analyses were performed to identify factors independently associated with abnormal postoperative temperatures. Results. 2,350 cases were included. 82% were normothermic postoperatively, while hypothermia and hyperthermia each occurred in 9% of cases. During the study period, hypothermia decreased from 24% to 2% (p < 0.0001) while hyperthermia remained unchanged (13% in 2006, 8% in 2014, p = 0.357). Factors independently associated with hypothermia were higher ASA status (p = 0.02), lack of intraoperative convective warming (p < 0.001) and procedure date before 2010 (p < 0.001). Independent associations for postoperative hyperthermia included lower body weight (p = 0.01) and procedure date before 2010 (p < 0.001). Conclusions. We report an increase in postoperative normothermia rates in critically ill infants from 2006 until 2014. Careful monitoring to avoid overcorrection and hyperthermia is recommended.

Ease of insertion of the laryngeal mask airway in pediatric surgical patients: Predictors of failure and outcome

BACKGROUND

Laryngeal mask airway (LMA) is an useful alternative to endotracheal tube for airway management. The risk of life-threatening adverse respiratory events during its use is rare, but we need to know about the risk-adjusted prediction of its insertion failure requiring rescue tracheal intubation and its impact on patient outcome.

MATERIALS AND METHODS

Five hundred patients; 6 months to 12-year-old, American Society of Anesthesiologists I and II scheduled to undergo elective surgical procedures that require general anesthesia were included in this study. LMA was inserted after induction of anesthesia. The insertion conditions, intra, and postoperative events were recorded. Our primary outcome variable was trial success from the first time.

RESULTS

We recorded 426 cases (85.2%) of first trial success with clear airway compared to 46 case (9.2%) of second trial success (P ≤ 0.001). Predictors of failure of first attempt of LMA insertion include abnormal airway anatomy (91%), body weight <16 kg and age below 5 years (44%), the use of LMA size of 1 and 1.5 (3.8%), the intraoperative lateral position (3.8%).

CONCLUSION

The data obtained from this study support the use of the LMA as a reliable pediatric supraglottic airway device, demonstrating relatively low failure rates. Predictors of LMA failure in the pediatric surgical population should be independently considered.

TRIAL REGISTRATION

The study is registered in the Australian and New Zealand clinical trial registry with the allocated trial number: ACTRN12614000994684. Web address of trial: http://www.ANZCTR.org.au/A CTRN12614000994684.aspx.

A comparison of classic laryngeal mask airway insertion between lightwand- and standard index finger-guided techniques

STUDY OBJECTIVE

To compare the efficacy of lightwand-guided classic laryngeal mask airway (cLMA) real-time insertion technique with the standard recommended index finger-guided insertion technique.

DESIGN

Prospective, randomized controlled study.

SETTING

University-affiliated hospital.

PATIENTS

Three hundred patients undergoing minor gynecological or orthopedic surgeries under general anesthesia using the cLMA as an airway management tool.

INTERVENTIONS

Patients were randomly divided into either lightwand-guided group or standard group.

MEASUREMENTS

Fiberoptic bronchoscopy was used to determine the cLMA position after a cLMA was inserted. The first attempt and total success rates of the cLMA insertion, insertion time, distances from the end of cLMA pilot tube to the upper central incisors, views of fiberoptic bronchoscopy, blood staining, tidal volume, airway pressure, end-tidal CO2, SpO2, noninvasive hemodynamic parameters, and others were compared.

MAIN RESULTS

The cLMA was all successfully inserted within 3 attempts except for 2 patients in the standard group. The success rates of lightwand-guided insertion technique at first attempt were significantly higher than standard insertion technique; the ideal view rates assessed by fiberoptic bronchoscopy in lightwand-guided group patients were also significantly higher than in standard group patients, but the insertion time of first successful attempt was similar; the blood staining rates on the cLMA in lightwand-guided group patients were significantly less than in standard group patients. The depths of cLMA insertion in standard group patients were significantly deeper than those in lightwand-guided group patients. There was no significant difference in end-tidal CO2, SpO2, airway pressure, and hemodynamic variables.

CONCLUSION

Lightwand-guided cLMA insertion technique can provide a more objective indicator for correct cLMA positioning, higher first attempt success rates, better glottic views, and less damage to oropharyngeal or esophagus tissues than standard index finger-guided cLMA insertion technique.

A randomized comparison of pediatric-sized Streamlined Liner of Pharyngeal Airway and Laryngeal Mask Airway-Unique in paralyzed children

BACKGROUND

The pediatric-sized Streamlined Liner of Pharyngeal Airway (SLIPA) is a new supraglottic airway device for children.

AIMS

The aim of this study was to compare the clinical performance of the pediatric-sized SLIPA with the Laryngeal Mask Airway-Unique in paralyzed children under positive pressure-controlled ventilation (PCV).

METHODS

One hundred children, aged 2 months to 12 years with American Society of Anesthesiologists physical status I-II were enrolled and randomly allocated to the SLIPA group or the Laryngeal Mask Airway-Unique group (50 patients in each group). The primary outcome variable was oropharyngeal leak pressure. Other outcome variables were first insertion success rate, insertion time, minor airway interventions required for successful insertion, intraoperative dislodgement, ventilatory data, and perioperative complications.

RESULTS

The insertion characteristics, ventilation data, and perioperative complications were comparable between the two groups. The leak pressure of the SLIPA was significantly higher than that of the Laryngeal Mask Airway-Unique [median (IQR): 25 (22-30) cm H2O vs. 21 (19-26) cm H2O, respectively; mean ± sd: 25.3 ± 4.6 cm H2O vs. 22.6 ± 4.8 cm H2O, respectively; P = 0.006]. The incidence of intraoperative dislodgment was significantly lower in the SLIPA group than in the Laryngeal Mask Airway-Unique group (0 vs. 6 patients, respectively; P = 0.027).

CONCLUSIONS

In conclusion, both the SLIPA and the Laryngeal Mask Airway-Unique can be used effectively without severe complications in paralyzed children. Additionally, the SLIPA provides a better airway seal and better intraoperative position stability than the Laryngeal Mask Airway-Unique.

[Continuous cuff pressure measurement during laryngeal mask anesthesia : An obligatory measure to avoid postoperative complications]

BACKGROUND

Inflation of laryngeal masks is often performed only with regard to the clinical impression and without any objective measurement of cuff pressure. As a result the use of laryngeal masks frequently leads to postoperative complications, such as sore throat, dysphonia, dysphagia and nerve palsy. In this study the influence of continuous measurement of cuff pressure on the incidence of postoperative sore throat was investigated in patients who underwent laryngeal mask anesthesia.

PATIENTS/MATERIAL AND METHODS

In the context of a retrospective audit all patients who underwent laryngeal mask anesthesia were asked to complete a questionnaire on anesthesia. The primary endpoint of the study was the postoperative occurrence of a sore throat. For analysis the patients were divided into two groups. In the first group the cuff pressure was controlled only by clinical means and in the second group the cuff pressure was controlled using continuous manometry. The study covered a 10-month period of observation for each group.

RESULTS

During the observation period laryngeal mask anesthesia was performed in 4169 patients. Of these 917 patients (manometry group n = 433 and control group n = 484) voluntarily completed the questionnaire. In the group without cuff pressure measurement 36 % of patients complained of sore throat postoperatively but only 12 % of the patients in the group with cuff pressure measurement (p < 0.001). Postoperative nausea and vomiting occurred in 16 % of the patients and 13 % complained of severe pain in the area of the operation. No differences between the two groups were found. While 97 % of patients in the group with continuous measurement of cuff pressure were satisfied with the anesthesia, this applied to only 79 % of patients in the control group (p = 0.006).

CONCLUSION

In terms of the results of this study and with respect to data from the literature, measurement of cuff pressure should be compulsory during laryngeal mask anesthesia.

Assessment before airway management

It is wise to plan and prepare for the unexpected difficult airway. Although it is essential to take a history and examine every patient prior to airway management, preoperative anticipation of a difficult airway occurs in only 50% of patients subsequently found to have a difficult airway. Bedside screening tests lack accuracy. The modified Mallampati test and the measurement of thyromental distance are unreliable for prediction of difficult tracheal intubation. Knowledge of risk factors for various airway management techniques may help when devising an airway management plan.

Advances in supraglottic airway devices for the management of difficult airways in children

There are innumerable tools and devices available to facilitate airway management and life-saving gas exchange of the patient's lungs. Over the years, various designs and generations of supraglottic airway devices have proven to be effective in accomplishing this function. Their application has grown beyond the original purpose of controlling the normal pediatric airway without tracheal intubation, and has been incorporated in the difficult airway management algorithms of anesthesia societies around the world based on clear evidence of efficacy. Older supraglottic airway devices since the 1980's have been validated in multiple clinical trials to be safe and effective in the pediatric population, however there is also sufficient evidence that the newer designs have features that help overcome some limitations. These newer designs and features are effective in managing both the normal and difficult pediatric airway, and will be discussed in this comprehensive review.

Small is the new big: An overview of newer supraglottic airways for children

Almost all supraglottic airways (SGAs) are now available in pediatric sizes. The availability of these smaller sizes, especially in the last five years has brought a marked change in the whole approach to airway management in children. SGAs are now used for laparoscopic surgeries, head and neck surgeries, remote anesthesia; and for ventilation during resuscitation. A large number of reports have described the use of SGAs in difficult airway situations, either as a primary or a rescue airway. Despite this expanded usage, there remains little evidence to support its usage in prolonged surgeries and in the intensive care unit. This article presents an overview of the current options available, suitability of one over the other and reviews the published data relating to each device. In this review, the author also addresses some of the general concerns regarding the use of SGAs and explores newer roles of their use in children.

A survey of practice patterns in the use of laryngeal mask by pediatric anesthesiologists

BACKGROUND

Laryngeal mask is frequently the airway device of choice in routine general anesthesia for many procedures in children. Several studies have described the use of laryngeal masks in unconventional situations. This survey was undertaken to assess how laryngeal masks are being used by pediatric anesthesiologists.

METHOD

The 40-question electronic survey using SurveyMonkey™ was sent to 2740 members of the Society for Pediatric Anesthesia (SPA). This survey assessed the age, work environment, types of practice, and training levels, as well as clinical situations in which the practitioners use laryngeal masks across different pediatric age groups.

RESULTS

Seven hundred and forty-three (27.1%) responses were obtained. The use of laryngeal mask increased as the patient age increased in nearly every queried situation. The practitioners routinely utilize laryngeal masks in a variety of challenging scenarios, such as in patients with a recent upper respiratory infection, in the difficult airway, remote locations, and long-duration surgeries. A small percentage of pediatric anesthesiologists use laryngeal masks in laparoscopic surgery and prone position procedures.

CONCLUSION

Pediatric anesthesiologists are using laryngeal masks in both routine and challenging/unconventional situations. Although many of the uses for laryngeal masks are not explicitly stated in the manufacturer guidelines, literature and current practice support the use of laryngeal masks in several of these scenarios.

LMA Supreme for neonatal resuscitation: study protocol for a randomized controlled trial

Background

The most important action in the resuscitation of a newborn in the delivery room is to establish effective assisted ventilation. The face mask and endotracheal tube are the devices used to achieve this goal. Laryngeal mask airways that fit over the laryngeal inlet have been shown to be effective for ventilating newborns at birth and should be considered as an alternative to facemask ventilation or endotracheal intubation among newborns weighing >2,000 g or delivered ≥34 weeks’ gestation. A recent systematic review and meta-analysis of supraglottic airways in neonatal resuscitation reported the results of four randomized controlled trials (RCTs) stating that fewer infants in the group using laryngeal mask airways required endotracheal intubation (1.5%) compared to the group using face masks (12.0%). However, there were methodological concerns over all the RCTs including the fact that the majority of the operators in the trials were anesthesiologists.

Our hypothesis is based on the assumption that ventilating newborns needing positive pressure ventilation with a laryngeal mask airway will be more effective than ventilating with a face mask in a setting where neonatal resuscitation is performed by midwives, nurses, and pediatricians. The primary aim of this study will be to assess the effectiveness of the laryngeal mask airway over the face mask in preventing the need for endotracheal intubation.

Methods/design

This will be an open, prospective, randomized, single center, clinical trial. In this study, 142 newborns weighing >1,500 g or delivered ≥34 weeks gestation needing positive pressure ventilation at birth will be randomized to be ventilated with a laryngeal mask airway (LMA Supreme^TM, LMA Company, UK - intervention group) or with a face mask (control group). Primary outcome: Proportion of newborns needing endotracheal intubation. Secondary outcomes: Apgar score at 5 minutes, time to first breath, onset of the first cry, duration of resuscitation, death or moderate to severe hypoxic-ischemic encephalopathy within 7 days of life.

Trial registration

ClinicalTrials.gov identifier: NCT01963936 (October 11, 2013).