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

I-gel Plus acts as a superior conduit for fiberoptic intubation than standard i-gel

The supraglottic airway (SGA) is widely used. I-gel Plus is a next-generation i-gel with some improvements, including facilitation of fiberoptic tracheal intubation (FOI). To compare the performance of i-gel Plus and standard i-gel as conduits for FOI, a Thiel-embalmed cadaveric study was conducted. Twenty-two anesthesiologists were enrolled as operators in Experiment 1. The i-gel Plus and standard i-gel were inserted into one cadaver, and the FOI was performed through each SGA. The primary outcome was time required for FOI. The secondary outcomes were the number of attempts and visual analog scale (VAS) score for difficulty in FOI. Moreover, fiberoptic views of the vocal cords in each SGA were assessed by an attending anesthesiologist using nine cadavers in Experiment 2. The percentage of glottic opening (POGO) score without fiberscope tip upward flexion and upward angle of the fiberscope tip to obtain a 100% POGO score were evaluated as secondary outcomes. The time for FOI through i-gel Plus was significantly shorter than that through standard i-gel (median (IQR), i-gel Plus: 30.3 (25.4-39.0) s, vs standard i-gel: 54.7 (29.6-135.0) s; median of differences, 24.4 s; adjusted 95% confidence interval, 3.0-105.7; adjusted P = 0.040). Although the number of attempts for successful FOI was not significantly different, the VAS score for difficulty in the i-gel Plus group was significantly lower (easier) than that in the standard i-gel group. Moreover, i-gel Plus required a significantly smaller upward angle of the fiberscope tip to obtain a 100% POGO score. FOI can be performed more easily using i-gel Plus than using standard i-gel because of the improved fiberoptic visibility of vocal cords.

[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.

Comparison of oropharyngeal leak pressure of I-gelTM and BlockbusterTM laryngeal mask airway in anaesthetized pediatric patients

BACKGROUND

Supraglottic airways (SGA) are increasingly used in pediatric anesthesia.Among SGA, I-gelTM is a commonly used device in pediatric patients. The BlockbusterTM laryngeal mask airway (LMA) is latest addition in pediatric airway armamentarium. This studywas conducted to compare the clinical performance of I-gelTM and BlockbusterTM LMA in pediatric patients.

METHODS

A total of 140 children aged 1-5 years, who were undergoing elective surgery,were randomized into two groups either I-gelTM (Group I) or BlockbusterTM LMA (Group B). Airway was secured with appropriate-sized LMA according to group allocation under generalanesthesia. The primary objective of study was oropharyngeal leak pressures (OPLP), andsecondary objectives were number of attempts of device insertion, success rate, ease ofLMA insertion, hemodynamic parameters, and postoperative pharyngolaryngeal morbidities.

RESULTS

The mean OPLP was significantly higher for I-gelTM compared to BlockbusterTM LMA(27.97 ± 1.65 vs. 26.04 ± 2.12; P < 0.001). The devices were successfully inserted on thefirst attempt in 97.14% and 90% of the Group I and Group B respectively. The insertion time,ease of insertion, hemodynamic parameters and postoperative complications were comparable between groups.

CONCLUSIONS

The I-gelTM was more efficacious device in term of OPLP than BlockbusterTMLMA for positive pressure ventilation in pediatric patients undergoing short surgical procedures under general anesthesia.

Intraoperative management for ex-utero intrapartum treatment: focusing on the fetus

Ex-utero intrapartum treatment (EXIT) is a method of securing the airway of a fetus while maintaining umbilical circulation for newborns who are experiencing life-threatening airway obstruction. Cesarean section is completed only after ensuring the neonate's safety. However, managing the airway of a neonate while maintaining umbilical circulation is a major challenge for anesthesiologists. Anesthesiologists must understand the physiology of both the mother and fetus, and extensive discussions with obstetricians, pediatricians, otolaryngologists, and nursing staff prior to the procedure are essential. This review provides an overview of the EXIT and details of airway management for neonates.

Comparison of the clinical performance of i-gel and Ambu laryngeal masks in anaesthetised paediatric patients: A meta-analysis

BACKGROUND

Paediatric supraglottic airway devices (SGAs) are widely used in routine anaesthesia and serve as primary or back-up devices for difficult airway management. The inflatable Ambu laryngeal masks and non-inflatable i-gel are two improvements of SGAs based on classic laryngeal masks. The clinical performance and safety of these two devices in paediatric patients are still unclear and warrant further investigation.

AIM

To perform a systematic review and meta-analysis on the clinical performance and safety of Ambu laryngeal masks and i-gel in anaesthetised paediatric patients.

METHODS

MEDLINE, Embase, Web of Science and Cochrane Central Register of Controlled Trials were searched from inception dates to April 2020. We identified published randomised controlled trials (RCTs) in which the intervention involved the use of Ambu laryngeal masks and i-gel in anaesthetised paediatric patients (age < 18 years). We assessed the oropharyngeal leak pressure (OLP) as the primary outcome. The secondary outcomes were insertion time, success rate of insertion on the first attempt, and incidence of adverse events.

RESULTS

After searching for all relevant trials published up to April 2020, data from seven RCTs with a total of 667 paediatric patients (323 and 344 participants in the i-gel and Ambu groups, respectively) were evaluated. The mean OLP in anaesthetised paediatric patients was lower in the Ambu group [21.82 cmH₂O for Ambu vs 23.98 cmH₂O for i-gel, P = 0.003, 95% confidence interval (CI): -3.58 to -0.75, I² = 68%, Mantel-Haenszel random model]. We did not find any clear evidence of differences between the devices in terms of insertion time, success rate of insertion, and incidence of adverse events except for blood staining (risk ratio 5.86, 95%CI: 1.76 to 19.46, P = 0.004, I² = 0, fixed-effect model).

CONCLUSION

The i-gel airway may provide a better seal and is therefore probably more suitable than the Ambu laryngeal mask airway in anaesthetised paediatric patients. However, the evidence is insufficient to allow making firm conclusions or to guide clinical practice, owing to the small number of relevant published studies.

Comparative study of Baska mask with proseal LMA in adult patients undergoing elective surgery under general anesthesia with controlled ventilation

Background and Aims:

Several supraglottic airway devices (SGD) are available nowadays. But none has been found to be better than Proseal laryngeal mask (PLMA) in terms of oropharyngeal leak pressure (OLP). We aimed to compare OLP of newly introduced Baska® Mask with PLMA in patients undergoing elective surgical procedures under general anesthesia.

Material and Methods:

Totally, 80 consecutive adult patients of either sex requiring general anesthesia were randomized into two groups Group B (Baska mask, n = 40) or Group P (PLMA. n = 40). After standardized induction with propofol 2 − 2.5 mg/kg^-1 and fentanyl 2 mgkg^-1, and muscle relaxation with vecuronium 0.1 mgkg^-1 one of the two devices was placed. OLP (primary outcome) was measured 5 minutes and 30 minutes post induction. The time needed to achieve effective airway, anatomical alignment of the device, number of attempts, leak fraction, and postoperative laryngopharyngeal morbidity were noted.

Results:

Both the devices could be inserted in first attempt in all the patients, but the time needed to achieve effective airway was significantly less in Group B (12.58 ± 1.81 sec vs 17.92 ± 2.45 sec, P < 0.001). The mean OLP was better in Group B at 5 min (37.6 ± 2.43 cm H₂O vs 30.82 ± 3.96 cm H₂O) and at 30 min (38.83 ± 1.72 cm H₂O vs 30.82 ± 3.96 cm H₂O; P < 0.001). Anatomical alignment of SGD with glottis (FOB grade 3 or 4 view) was significantly better in group B (34/40) as compared to group P (25/40) (p = 0.009). There was no difference in laryngopharyngeal morbidity in the two groups.

Conclusion:

Baska mask provided higher OLP, better alignment to the glottis and faster placement time as compared to PLMA.

Comparison of the efficacy of supraglottic airway devices in low-risk adult patients: a network meta-analysis and systematic review

Numerous supraglottic airway device (SADs) have been designed for adults; however, their relative efficacy, indicated by parameters such as adequacy of sealing, ease of application, and postinsertion complications, remains unclear. We conducted a systematic review and network meta-analysis to evaluate the efficacy of various SADs. We searched electronic databases for randomized controlled trials comparing at least two types of SADs published before December 2019. The primary outcomes were oropharyngeal leak pressure (OLP), risk of first-attempt insertion failure, and postoperative sore throat rate (POST). We included 108 studies (n = 10,645) comparing 17 types of SAD. The Proseal laryngeal mask airway (LMA), the I-gel supraglottic airway, the Supreme LMA, the Streamlined Liner of the Pharynx Airway, the SoftSeal, the Cobra Perilaryngeal Airway, the Air-Q, the Laryngeal Tube, the Laryngeal Tube Suction II, the Laryngeal Tube Suction Disposable, AuraGain, and Protector had significantly higher OLP (mean difference ranging from 3.98 to 9.18 cmH₂O) compared with that of a classic LMA (C-LMA). The Protector exhibited the highest OLP and was ranked first. All SADs had a similar likelihood of first-attempt insertion failure and POST compared with the C-LMA. Our findings indicate that the Protector may be the best SAD because it has the highest OLP.Systematic review registration PROSPERO: CRD42017065273.

Comparative effectiveness of pharmacological interventions to prevent postoperative delirium: a network meta-analysis

Many pharmacologic agents were investigated for the effect to prevent delirium. We aimed to comprehensively compare the effect of the pharmacological interventions to prevent postoperative delirium. A Bayesian network meta-analysis of randomized trials was performed using random effects model. PubMed, the Cochrane Central Register of Controlled Trials, and Embase were searched on 20 January 2021. Randomized trials comparing the effect of a drug to prevent postoperative delirium with another drug or placebo in adult patients undergoing any kind of surgery were included. Primary outcome was the postoperative incidence of delirium. Eighty-six trials with 26,992 participants were included. Dexmedetomidine, haloperidol, and atypical antipsychotics significantly decreased the incidence of delirium than placebo [dexmedetomidine: odds ratio 0.51, 95% credible interval (CrI) 0.40-0.66, moderate quality of evidence (QOE); haloperidol: odds ratio 0.59, 95% CrI 0.37-0.95, moderate QOE; atypical antipsychotics: odds ratio 0.27, 95% CrI 0.14-0.51, moderate QOE]. Dexmedetomidine and atypical antipsychotics had the highest-ranking probabilities to be the best. However, significant heterogeneity regarding diagnostic time window as well as small study effects precludes firm conclusion.

Impact of visually guided versus blind techniques of insertion on the incidence of malposition of Ambu® AuraGain™ in paediatric patients undergoing day care surgeries: A prospective, randomised trial

BACKGROUND AND AIMS

In adults, video laryngoscopy is recommended for supraglottic airway device (SGAD) placement as it results in better device position and higher oropharyngeal leak pressures. In children, there is a paucity of studies evaluating the impact of visually guided techniques on SGAD placement. Aim of the study was to evaluate the usefulness of visual-guided techniques of SGAD placement in children.

METHODS

Totally, 75 children, scheduled for elective surgery, were randomly allocated into three groups, that is, standard (S), direct laryngoscopy (DL), and video laryngoscopy (VL). Ambu AuraGain was placed blindly in group S, and under visual guidance with video laryngoscopy and direct laryngoscopy in groups VL and DL, respectively. Ambu AuraGain position was determined by flexible videoendoscope. First attempt success rate, time for successful insertion, oropharyngeal leak and any complications were studied.

RESULTS

Incidence of malposition was not significantly different in group S (44%), DL (48%), and VL (64%); P = 0.32. The first attempt success rate was 100% in DL and 92% each in S and VL. Time to insert (seconds) was significantly higher in VL (37.9 ± 21.6), compared to S (18.4 ± 7.9) and DL (27.4 ± 14.5); P <0.001. Incidence of oropharyngeal leak, impact on ventilation, and complications were similar in all three groups.

CONCLUSION

In this study, there was no advantage of visually guided techniques for Ambu AuraGain placement in children.

Clinical performance of Ambu AuraGainTM versus i-gelTM in anesthetized children: a prospective, randomized controlled trial

Background

Ambu AuraGain and i-gel have different characteristics in design each other. However, few reports evaluate which device has more benefits for ventilation in children undergoing paralyzed general anesthesia. This prospective, randomized controlled trial compared the clinical performance AuraGain and i-gel in anesthetized children.

Methods

Children aged between 1 month and 7 years undergoing elective surgery were randomly assigned to the AuraGain and i-gel groups. The primary outcome was initial oropharyngeal leak pressure (OLP). Secondary outcomes were OLP at 10 min post-insertion, first-attempt and total insertion success rates, number of attempts and ease of gastric suction catheter placement, peak inspiratory pressure, fiberoptic bronchoscopic view score, ventilation quality, requirement of additional manipulation post-insertion, and complications.

Results

Data of 93 patients were analyzed. The initial OLPs of the AuraGain and i-gel were 27.5 ± 7.7 and 25.0 ± 8.0 cmH₂O, respectively (P = 0.130). The OLP was significantly increased 10 min post-insertion in both groups. The initial success rates of the AuraGain and i-gel insertion were comparable. Suction catheter placement via the gastric port was easier (P = 0.018) and fiberoptic bronchoscopic view was better with the AuraGain (P < 0.001). The i-gel required additional manipulations post-insertion (P = 0.038). The incidence of complications during the emergence period was 10.8% for the i-gel^TM and 2.2% for the AuraGain (P = 0.1)

Conclusions

OLP is comparable between AuraGain and i-gel. The AuraGain would be more favorable than the i-gel^TM for use in pediatric patients under general anesthesia considering other outcomes.

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.

Feasibility of forced oscillatory assessment of respiratory mechanics across a laryngeal mask airway in rabbits

OBJECTIVES

The forced oscillation technique (FOT) is the method of choice for assessment of respiratory tissue mechanics. A laryngeal mask airway (LMA) is increasingly used to secure the airways in subjects under sedation or general anesthesia. While FOT is routinely performed using an endotracheal tube (ETT), the accuracy of information about airway and tissue mechanics obtained with FOT using a LMA has not been characterized. Therefore, we compared the mechanical parameters obtained with FOT using LMA and ETT in rabbits.

APPROACH

FOT was performed through a LMA at normal and reduced oscillatory amplitudes in anesthetized and mechanically ventilated rabbits (n  =  9) at positive end-expiratory pressures (PEEP) of 3 and 6 cmH₂O. These measurements were repeated at normal amplitude for the same animal using an ETT. Airway resistance, inertance, respiratory tissue damping (G) and elastance (H) were measured under each condition by FOT. The potential bias of the distensible upper airways when FOT was applied using LMA was assessed with a simulation study.

MAIN RESULTS

Values of parameters reflecting airway mechanics were significantly higher when measured using LMA at both PEEPs and oscillatory amplitudes than with ETT. Conversely, regardless of the condition, there was a correlation (r  =  0.89 both at normal and reduced amplitudes; p   <  0.0001) with good agreement (mean bias of 8.8 cmH₂O/l and 11.3 cmH₂O/l) in H, whereas G was systematically lower when obtained with LMA than with ETT at PEEP 3 (21.1%  ±  7.2% and 9.6%  ±  6.9% at normal and reduced oscillatory amplitudes, respectively) and 6 cmH₂O (15.1%  ±  8.2%, 1.6%  ±  9.4%, p   <  0.05 for all).

SIGNIFICANCE

Mechanical properties of the airways and the respiratory tissues, particularly for respiratory tissue stiffness, can be reliably assessed using LMA. However, the involvement of a longer laryngo-tracheo-bronchial pathway when using LMA should be considered for airway resistance and inertance, whereas upper airway shunting may affect the assessment of respiratory tissue damping.

Getting it right first time: time to simplify our approach to the airway by using our best tools first

Deciding on the techniques and equipment to use when managing a patient’s airway during anaesthesia is a complex process. It is influenced by many factors, including the type of surgery being undertaken, patient co-morbidities, perceived risk of airway difficulty or pulmonary aspiration and the availability of more advanced equipment. While there are many guidelines for management of the unanticipated difficult airway, there are few if any for routine airway management. It is likely that current practices are heavily influenced by national and institutional norms, personal experiences and preferences of the individual anaesthetist involved.