Comparison of insertion characteristics of LMA ProSeal from the front and head-end of the patient: A randomized pilot study

Background and Aims

LMA ProSeal (PLMA) is a commonly used airway maintenance device in elective procedures and is routinely inserted from the head-end of the patient. It is also used in pre-hospital emergencies where it may not always be possible to access the head-end. This study aims to compare the insertion characteristics of PLMA when inserted while standing, either at the head-end or from the front.

Material and Methods

After institutional ethics committee approval, 60 consenting patients of either sex, between 18 and 60 years, ASA class I/II, and scheduled to undergo elective surgeries were randomly allocated to either group H (head-end insertion) or group F (front-end insertion). Patients with anticipated difficult airway, chronic respiratory disease, obesity, and who were pregnant were excluded. Insertion time, ease of insertion, fiber optic view, ease of drain tube insertion, number of attempts and success rate were noted. Normally distributed quantitative variables were compared using t-test, and qualitative variables were compared using Chi-squared test. A P < 0.05 was considered significant.

Results

Insertion time in group H (23.76 ± 4.48 s) was lesser than in group F (30.53 ± 6.23s) (P = 0.027). Ease of insertion (P = 0.052), fiber optic view, ease of drain tube placement (P = 1.000), and number of attempts (P = 1.000) were comparable among the groups.

Conclusion

Although the insertion time from the front is longer than from the head-end, the other insertion characteristics of PLMA including ease of its insertion, placement and success rate of placement are similar when it is inserted from the front or from the head-end. It is an appropriate airway device for securing the airway when the head-end is inaccessible.

The effect of class 3 obesity on the functionality of supraglottic airway devices: a historical cohort analysis with propensity score matching

PURPOSE

Supraglottic airway devices (SGAs) have been increasingly used as a primary airway in patients undergoing anesthesia as an alternative to endotracheal tubes. Second-generation devices have expanded their applicability to include uses in patients with obesity. Nevertheless, there is limited evidence of SGA suitability for patients with class 3 obesity (body mass index [BMI] ≥ 40 kg·m-2). As such, we compared rates of SGA functionality between patients with class 3 obesity and patients without class 3 obesity undergoing general anesthesia.

METHODS

We performed a propensity score matching analysis using inverse probability of treatment weighting to compare the functionality of SGAs in adult patients with class 3 obesity vs without class 3 obesity. These patients underwent surgery at a hospital in Queensland, Australia from November 2017 to September 2020 and had a SGA inserted as part of their anesthetic care. All data were collected from patients' electronic medical records. We included 321 patients in the cohort with class 3 obesity and 471 in the cohort without class 3 obesity (control/comparison). The estimated effect of class 3 obesity on SGAs was calculated using adjusted odds ratios (AORs) with their 95% confidence intervals (CIs).

RESULTS

The overall weighted prevalence of nonfunctional SGAs was 3.2%, with a significantly higher rate in the class 3 obesity cohort compared with the control cohort (4.7% vs 2.1%) (P = 0.04). This adjusted analysis illustrates that class 3 obesity was associated with an almost four times higher odds of a nonfunctional SGA (odds ratio [OR], 2.3; 95% CI, 1.0 to 5.1; AOR, 3.9; 95% CI, 1.4 to 10.6) than patients without class 3 obesity.

CONCLUSION

Patients with class 3 obesity (BMI ≥ 40 kg·m-2) had greater than three-fold odds of nonfunctional intraoperative SGAs than patients without class 3 obesity.

Assessing a novel second generation laryngeal mask airway using the 'ADEPT' approach: results from the LMA® Protector™ observational study

To address the problem of lack of clinical evidence for airway devices introduced to the market, the Difficult Airway Society (UK) developed an approach (termed ADEPT; Airway Device Evaluation Project Team) to standardise the model for device evaluation. Under this framework we assessed the LMA Protector, a second generation laryngeal mask airway. A total of 111 sequential adult patients were recruited and the LMA Protector inserted after induction of general anaesthesia. Effective insertion was confirmed by resistance to further distal movement, manual ventilation, and listening for gas leakage at the mouth. The breathing circuit was connected to the airway channel and airway patency confirmed with manual test ventilation at 20 cm H20 (water) pressure for 3 s. Data was collected in relation to the time for placement, intraoperative performance and postoperative performance of the airway device. Additionally, investigators rated the ease of insertion and adequacy of lung ventilation on a 5-point scale. The median (interquartile range [range]) time taken to insertion of the device was 31 (26-40[14-780]) s with the ability to ventilate after device insertion 100 (95% CI 96.7- 100)%. Secondary endpoints included one or more manoeuvres 60.3 (95% CI 50.6-69.5)% cases requiring to assist insertion; a median ease of insertion score of 4 (2-5[3-5]), and a median adequacy of ventilation score of 5 (5-5[4-5]). However, the first time insertion rate failure was 9.9% (95% CI 5.1-17.0%). There were no episodes of patient harm recorded, particularly desaturation. The LMA Protector appears suitable for clinical use, but an accompanying article discusses our reflections on the ADEPT approach to studying airway devices from a strategic perspective.

Nor N, Mohd Azidin A, Low HJ, Mohamad Mahdi SN. Evaluating the Optimal Operating Table Height for ProSeal-LMA™ Insertion

INTRODUCTION

ProSeal-Laryngeal Mask Airway™ (P-LMA™) is one of the commonly used laryngeal mask airways. Despite the proper insertion technique, suboptimal positioning and airway morbidity still occurs. This study explored the possibility of the operating table height position affecting successful P-LMA™ placement.

METHODS

A total of 138 patients aged between 18 and 65 years old with the American Society of Anesthesiologists (ASA) I or II status, who required general anaesthesia and had no contraindication towards the use of P-LMA™, were recruited. They were randomly positioned into three anatomical landmarks, which were umbilicus, lowest rib margin, and xiphoid. P-LMA™ was inserted following muscle paralysis, and the first successful placement was evaluated using positional and performance tests. Duration, ease of P-LMA™ insertion, and airway complications were compared.

RESULTS

Demographic and airway features were comparable among all groups. The P-LMA™ placement success rate improved when the table height was positioned at the lowest rib margin (p=0.002). All three positions were comparable in terms of duration, ease of insertion, and airway morbidities.

CONCLUSION

The lowest rib margin anatomical landmark can be used as a guide in achieving the optimal operating table height for successful P-LMA™ placement.

Management of the Unexpected Difficult Airway in Neonatal Resuscitation

A "difficult airway situation" arises whenever face mask ventilation, laryngoscopy, endotracheal intubation, or use of supraglottic device fail to secure ventilation. As bradycardia and cardiac arrest in the neonate are usually of respiratory origin, neonatal airway management remains a critical factor. Despite this, a well-defined in-house approach to the neonatal difficult airway is often lacking. While a recent guideline from the British Pediatric Society exists, and the Scottish NHS and Advanced Resuscitation of the Newborn Infant (ARNI) airway management algorithm was recently revised, there is no Norwegian national guideline for managing the unanticipated difficult airway in the delivery room (DR) and neonatal intensive care unit (NICU). Experience from anesthesiology is that a "difficult airway algorithm," advance planning and routine practicing, prepares the resuscitation team to respond adequately to the technical and non-technical stress of a difficult airway situation. We learned from observing current approaches to advanced airway management in DR resuscitations in a university hospital and make recommendations on how the neonatal difficult airway may be managed through technical and non-technical approaches. Our recommendations mainly pertain to DR resuscitations but may be transferred to the NICU environment.

Clinical Outcomes of a Modified Laryngeal Mask Airway (LMA® Gastro™ Airway) During Esophagogastroduodenoscopy in Children and Adolescents: A Randomized Study

Introduction

During esophagogastroduodenoscopy (EGD), general anesthesia (GA) may be provided using a laryngeal mask airway (LMA) with the endoscope inserted behind the cuff of the LMA into the esophagus. Passage of the endoscope may increase the intracuff of the LMA. We evaluated a newly designed LMA (LMA^® Gastro™ Airway) which has an internal channel exiting from its distal end to facilitate EGD. The current study compared the change of LMA cuff pressure between this new LMA and a standard clinical LMA (Ambu^® AuraOnce™) during EGD.

Methods

Patients less than 21 years of age and weighing more than 30 kg were randomized to receive airway management with one of the two LMAs during EGD. After anesthetic induction and successful LMA placement, the intracuff pressure of the LMAs was continuously monitored during the procedure. The primary outcome was the change of intracuff pressure of the LMAs.

Results

The study cohort included 200 patients (mean age 13.6 years and weight 56.6 kg) who were randomized to the LMA^® Gastro™ Airway (n=100) or the Ambu^® AuraOnce™ LMA (n=100). Average intracuff pressures during the study period (before and after endoscope insertion) were not different between the two LMAs. Ease of the procedure was slightly improved with the LMA^® Gastro™ Airway (p<0.001).

Discussion

The LMA^® Gastro™ Airway blunted, but did not prevent an increase in intracuff pressure during EGD when compared to the Ambu^® AuraOnce™ LMA. Throat soreness was generally low, and complications were infrequent in both groups. The ease of the procedure was slightly improved with the LMA^® Gastro™ Airway compared to the Ambu^® AuraOnce™ LMA.

Efficacy of Baska mask and Laryngeal mask airway supreme during positive pressure ventilation - A comparative study

Background and Aims:

Supraglottic airway devices have several roles including maintenance of a clear upper airway during general anesthesia. We primarily compared the efficacy of Baska mask (BM) and laryngeal mask airway supreme (LMAS) for the rate of first time successful placement and the seal pressure. The secondary outcome measures included laryngopharyngeal morbidity and the correct positioning of the gastric port.

Material and Methods:

A sample size of 30 was calculated in each study group. A total of 70 study participants were included in the statistical analysis of which 36 patients were in the BM group and 34 patients were in the LMAS group.

Results:

The BM was successfully inserted in 28 patients (77.8%), whereas LMAS was successfully inserted in 33 patients (97.1%) in the first attempt (P = 0.028). The mean oropharyngeal seal pressure in the BM group was higher (33.28 ± 6.80 cm H₂O) than compared to the LMAS group (27.47 ± 2.34 cm H₂O) with a P value <0.001. There was no significant difference between the two groups in the incidence of postoperative laryngopharyngeal morbidity both in the immediate postoperative period (P = 0.479) and that seen 24 hours post operatively (P = 0.660). The nasogastric tube could easily be inserted in the entire study population.

Conclusion:

From the present study, it is concluded that the BM creates a higher oropharyngeal seal pressure than the LMAS. However, the BM is more difficult to insert. The incidence of postoperative laryngopharyngeal morbidity is similar in both groups.

A comparison of supraglottic devices in pediatric patients

Background

When managing patients with a difficult airway, supraglottic airways (SGAs) have been used as rescue devices or to serve as a conduit for endotracheal intubation. The current study compares various clinical outcomes, including the bronchoscopic view of the glottis when using 2 SGAs, the Air-Q^® laryngeal mask airway (LMA) and the i-gel^® SGA, in pediatric patients.

Methods

Patients ≤18 years of age were prospectively randomized to receive either the Air-Q^® LMA or the i-gel^® SGA. Following SGA placement, a flexible fiberoptic bronchoscope was inserted through the SGA to visualize the glottis. Time taken to obtain the bronchoscopic view and place the SGA, and the ability to seal the airway at 20 cmH₂O were compared. The bronchoscopic view obtained was graded as follows: 1) glottic aperture seen completely; 2) glottic aperture seen partially with visual obstruction <50%; 3) glottic aperture seen, but visual obstruction >50%; and 4) glottic aperture not seen.

Results

Fifty patients were enrolled and 48 (22/26 male/female) were included in the analysis. Median age was 13 years (IQR: 7, 16) and median weight was 49 kg (IQR: 25, 70). The Air-Q^® LMA and i-gel^® SGA groups did not differ in device placement time (median of 19 vs 21 seconds; 95% CI of difference in medians: - 2 to 7; P=0.331), the time to achieve fiberoptic view of the glottis (median of 25 vs 21 seconds; 95% CI of difference: - 9 to 8; P=0.489) or the grade of the bronchoscopic view of the airway. Eight Air-Q^® and 6 i-gel^® supraglottic devices sealed the airway at 20 cmH₂O.

Discussion

The time required for successful placement of the SGA, the time required for bronchoscopic view, and the quality of bronchoscopic view through the Air-Q^® LMA and the i-gel^® SGA did not differ.

Comparision of Ambu AuraGain™ and LMA® ProSeal in children under controlled ventilation

BACKGROUND AND AIMS

The LMA ProSeal® is considered a prototype among the second-generation supraglottic airway devices (SAD). The Ambu AuraGain™ is a relatively new, single use, second-generation SAD with a preformed shape. We conducted this study with the aim of comparing the difference in clinical performance between Ambu AuraGain™ and LMA ProSeal® in children receiving controlled ventilation.

METHODS

Ninety-four children, aged between 6 months to 12 years, weighing 5 to 30 kg, belonging to American Society of Anesthesiologists Physical Status I and II, undergoing elective surgical procedures, were randomized into two groups. The primary end-point was oropharyngeal seal pressure, and the secondary parameters were the number of attempts, time of insertion, ease of placement of the device and gastric tube, and fiberoptic visualization of the laryngeal aperture.

RESULTS

The mean oropharyngeal seal pressure with Ambu AuraGain™ was significantly higher than LMA ProSeal® (23.3 ± 4.6 cmH2O vs 20.6 ± 4.8 cmH2O, P = 0.007, respectively). The ease and success rate for device placement, fiberoptic visualization of the larynx, and complications were comparable. However, the time for insertion in Ambu AuraGain™ group was shorter when compared to LMA ProSeal® group, median (IQR [range]); 12 (10-15) s vs 20 (18-23) s (P < 0.001), respectively. The gastric drain was significantly easier to insert in Ambu AuraGain™ compared to LMA® ProSeal (P = 0.01).

CONCLUSION

Our study suggests that Ambu AuraGain™ could be a useful disposable alternative to LMA ProSeal® for securing airway in children.

Comparison of laryngeal tube suction II and proseal LMA™ in pediatric patients, undergoing elective surgery

BACKGROUND

Supraglottic airway devices now have an established place in pediatric anesthesia practice. The laryngeal tube suction (LTS) II, a recent revision of the LTS, has very few studies evaluating its use in pediatric patients. The aim of this study was to compare insertion and ventilation profiles of the LTS-II size 2 and the ProSeal™ Laryngeal Mask Airway (PLMA) size 2 in pediatric patients undergoing elective surgeries.

MATERIALS AND METHODS

A randomized prospective study was conducted in 100 children aged 2-5 years between 12 and 25 kg weight, of the American Society of Anesthesiologists physical status I and II scheduled for routine elective surgeries of <90 min duration. They were randomly divided into two groups of 50 each, depending on the device inserted, and a standard protocol for anesthesia was followed. Outcome measures were studied in terms of ease and time of insertion, oxygen saturation (SpO2), oropharyngeal seal pressure (OSP), and ventilation failures.

RESULTS

Both groups were well matched in terms of age, weight, and type of surgery. The success rate for the first attempt was 90% for both the LTS-II group and PLMA group. Insertion was found to be easy in the majority of cases in both groups, and there was no statistical difference in blood pressure, heart rate, or SpO2 on insertion. However, the OSP was significantly more in LTS-II and PLMA (P < 0.001). There were no clinically important complications in the postoperative period.

CONCLUSIONS

Pediatric size 2 LTS-II is easy to insert and provides higher OSP compared with same size PLMA in anesthetized and paralyzed children undergoing elective surgery. It is a safe alternative to PLMA in short duration elective surgeries and may be a better device as it provides for higher OSPs.

A comparison of i-gel™ and Laryngeal Mask Airway Supreme™ during general anesthesia in infants

Background

The i-gel™ (i-gel) and Laryngeal Mask Airway Supreme™ (LMA Supreme) have been safely used in children. We compared the airway performance of the i-gel and LMA Supreme in infants undergoing general anesthesia.

Methods

Sixty infants with American Society of Anesthesiologists physical status I or II were randomly assigned to place either the i-gel or the LMA Supreme. The size 1 or 1.5 of each airway was selected by the weight of infants. The primary outcome variable was oropharyngeal leak pressure (OLP). We also assessed insertion success rate, insertion time, fiberoptic view of the larynx, airway quality, airway manipulations, and perioperative complications.

Results

Demographic data did not differ between the two groups. Insertion success rate was similar in both groups. OLP for the i-gel (26.0 ± 3.8 cmH₂O) was higher than for the LMA Supreme (23.7 ± 3.2 cmH₂O) (P = 0.016). Insertion time for the i-gel (16.4 ± 2.8 s) was shorter than for the LMA Supreme (18.5 ± 2.7 s) (P = 0.002). There were no differences in fiberoptic view of the larynx, airway quality, airway manipulations, and complications between the two groups.

Conclusions

This study demonstrated that the i-gel and LMA Supreme provided a similar performance of airway in infants. Compared with the LMA Supreme, the i-gel provided shorter insertion time and higher OLP in infants.

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.

Ambu® Auragain™ versus LMA Supreme™ Second Seal™: A Randomised Controlled Trial Comparing Oropharyngeal Leak Pressures and Gastric Drain Functionality in Spontaneously Breathing Patients

Newer second generation supraglottic airway devices may perform differently in vivo due to material and design modifications. We compared performance characteristics of the Ambu® AuraGain™ and LMA Supreme™ Second Seal™ in 100 spontaneously breathing anaesthetised patients in this randomised controlled study. We studied oropharyngeal leak pressures (OLP) (primary outcome) and secondarily, ease of insertion, success rates, haemodynamic response, time to insertion, and complications of usage. We found no significant difference in OLP between the AuraGain versus the LMA Supreme, mean (standard deviation, SD) 24.1 (7.4) versus 23.6 (6.2) cmH2O, P=0.720. First-attempt placement rates of the AuraGain were comparable to the LMA Supreme, 43/50 (86%) versus 39/50 (78%), P=0.906, with an overall 98% insertion success rate for the AuraGain and 88% for the LMA Supreme after three attempts, P=0.112. However, the AuraGain was deemed subjectively harder to insert, with only 24/50 (48%) versus 37/50 (74%) of AuraGain insertions being scored 1 = easy (on a 5 point scale), P=0.013, and also took longer to insert, 33.4 (SD 10.9) versus 27.3 (SD 11.4) seconds, P=0.010. The AuraGain needed a smaller volume of air (16.4 [SD 6.8] versus 23.0 [SD 7.4] ml, P <0.001) to attain intracuff pressures of 60 cmH2O, facilitated more successful gastric tube insertion (100% versus 90.9%, P=0.046), and had significantly decreased sore throat incidence (10% versus 38%, P=0.020). One AuraGain and six LMA Supremes failed to be placed within the stipulated 120 seconds trial definition of ‘success’; these patients had risk factors for failed supraglottic insertion. In conclusion, both devices had similar OLPs and performed satisfactorily. However, the AuraGain resulted in less postoperative sore throat despite being harder to, and taking longer to, insert.

Observation of ventilation effects of I-gel™, Supreme™ and Ambu AuraOnce™ with respiratory dynamics monitoring in small children

The shortcomings of laryngeal mask airway (LMA™), such as upper airway obstruction and gastric distension or airway leakage, may limit its application in small children. The I-gel™ (I-gel), LMA-Supreme™ (LMA-S), and Ambu AuraOnce™ (Ambu) are three improvements upon these shortcomings. This study adopted respiratory dynamic monitoring to observe the ventilation parameters of the three laryngeal masks in small children. A total of 105 children were randomized into Ambu (n = 35), I-gel (n = 35), and LMA-S (n = 35) groups. Primary outcomes included leak pressure and respiratory dynamic data. Secondary outcomes included hemodynamic data and bispectral index values after induction (T₀), time after successful laryngeal mask insertion (T₁) and at three recording points every 10 min after insertion (T₂, T₃, and T₄), as well as laryngeal mask related adverse reactions. The inspiratory/expiratory tidal volume per kilogram of body weight in the Ambu group was significantly different from those in the other groups (P < 0.05), while the leak pressure in the Ambu group was significantly lower (P < 0.05). At T₃ and T₄, the expiratory resistance values in the Ambu group were significantly lower than those in the LMA-S group (P < 0.05). We have shown that the three laryngeal masks provided secure ventilation in children <6 years of age by using continuous respiratory dynamic monitoring. We concluded that the I-gel presented a better sealing effect and fewer adverse reactions.

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.

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.

Application of the LMA-Supreme™ and i-gel™ laryngeal masks during pelvic operations in adults

OBJECTIVE

The aim of this study was to evaluate the practical application and safety of the i-gel and LMA-Supreme laryngeal masks for airway management during pelvic operations in adults.

METHODS

Ninety patients undergoing general anesthesia for elective pelvic operations (ASA Grades I-II) were randomly divided into two groups, the i-gel group and the Supreme group. The laryngeal mask was inserted after induction, and the relevant examination grading indexes were recorded.

RESULTS

The Supreme group required less time for laryngeal mask insertion and gastric tube indwelling time. Gastric tube indwelling was easier, compared with those in the i-gel group (p = 0.03), but the i-gel group had fewer complications (p = 0.03). There were no significant differences in the degree of difficulty in insertion, airway sealing pressure, PETCO2, Ppeak, and laryngeal mask alignment accuracy between the two groups (p > 0.05). There was no statistically significant difference in fibrobronchoscopy grading between the two groups (p > 0.05).

CONCLUSION

The i-gel and LMA-Supreme laryngeal masks are safe and effective for airway management in patients during pelvic operations.

Performance of size 1 I-gel compared with size 1 ProSeal laryngeal mask in anesthetized infants and neonates

Purpose. The size 1 I-gel, recommended for small infants and neonates weighing 2–5 kg, has recently been released. There are no prospective studies available that assess the insertion conditions, sealing pressures, or ventilation quality of it. This study was designed to compare the performance of recently released size 1 I-gel with size 1 ProSeal LMA. Methods. Fifty infants and neonates, ASA I-II were included in this prospective, randomized, and controlled study. Patients were divided into two groups for placing I-gel or ProSeal LMA. The primary outcome was airway leak pressure, and secondary outcomes included insertion time, insertion success and conditions, initial airway quality, fiberoptic view of the larynx, and complications. Results. There were no significant differences in terms of airway leak pressure between the I-gel (27.44 ± 5.67) and ProSeal LMA (23.52 ± 8.15) (P = 0.054). The insertion time for the I-gel was shorter (12.6 ± 2.19 s) than for the ProSeal LMA (24.2 ± 6.059 s) (P = 0.0001). Insertion success and conditions were similar in groups. We encountered few complications. Conclusion. Our study demonstrates that the size 1 I-gel provided an effective and satisfactory airway as the size 1 ProSeal LMA. It may be a good alternative supraglottic airway device for use in small infants and neonates. This trial is registered with: ClinicalTrials.gov NCT01704118.

A comparison of i-gel™ and LMA Supreme™ in anesthetized and paralyzed children

Background

Both the i-gel™ (i-gel) and LMA Supreme™ (Supreme) are new single-use second generation supraglottic airway devices available in pediatric sizes. This study was designed to investigate the i-gel in comparison with the Supreme in children undergoing general anesthesia.

Methods

One hundred children with American Society of Anesthesiologists physical status I or II undergoing general anesthesia were randomly assigned to either the i-gel or the Supreme group (50 children in each group). The device size was chosen according to weight of the children. We assessed the insertion success rate, insertion time, oropharyngeal leak pressure, grade of the fiberoptic glottic view, number of airway manipulations required, and postoperative complications.

Results

There were no differences in the demographic data between the two groups. The success rate of insertion was same in both groups. The insertion time of the i-gel was longer than that of Supreme (P = 0.004). The oropharyngeal leak pressure in the i-gel group was higher than that in the Supreme group (P = 0.013). On fiberoptic examination, the vocal cords were visible in 90% of the children in the i-gel group and in 96% of the children in the Supreme group. The number of airway manipulations required was higher in the i-gel group (14 cases) than in the Supreme group (1 case) (P < 0.001). There were no differences in complications including blood staining of the device and sore throat between both groups.

Conclusions

Both the i-gel and Supreme provided a satisfactory airway during general anesthesia in children. Compared to the Supreme, the i-gel demonstrated a higher oropharyngeal leak pressure, longer time for insertion, and a greater number of airway manipulations during anesthesia.

The LMA-Supreme versus the I-gel in simulated difficult airway in children: a randomised study

BACKGROUND

Supraglottic airway devices such as the LMA-Supreme (LMA-S) and I-gel, which have an additional lumen for the insertion of a gastric tube, can be useful in the management of the difficult airway.

OBJECTIVE

To test the performance of these two devices in the difficult paediatric airway.

DESIGN

Randomised double-blind study.

SETTING

Anaesthesia department, university hospital.

PATIENTS

Sixty American Society of Anesthesiologists (ASA) I-II children undergoing elective surgery.

INTERVENTION

After obtaining ethical approval and written informed consent from the parents, we compared the size 2 LMA-S with the I-gel in a simulated airway scenario made more difficult by using a cervical collar to limit mouth opening and neck movement.

MAIN OUTCOME MEASURES

The primary aim was to compare the oropharyngeal leak pressure of the LMA-S and the I-gel. The secondary aims were to compare success rate, insertion time, time to pass a gastric tube and fibreoptic view of the larynx.

RESULTS

Oropharyngeal leak pressure (mean ± SD) for the LMA-S was significantly higher than with the I-gel (20.9 ± 3.2 versus 18.9 ± 3.2 cmH2O, P = 0.019). First attempt success rate for the LMA-S was 100 and 90% for the I-gel (P > 0.05). Insertion time of the LMA-S was shorter than I-gel (11.2 ± 1.8 versus 13.5 ± 2.4 s, P = 0.001). Gastric tube placement was possible in all patients. The mean insertion time of the gastric tube was shorter with the LMA-S than with the I-gel (10.3 ± 3.6 versus 12.7 ± 3.2 s, P = 0.009). Fibreoptic laryngeal views were similar in both groups.

CONCLUSION

In the simulated difficult airway in children, both airway devices provided effective ventilation. Paediatric size 2 LMA-S sustained a higher airway pressure before leaking and was quicker to insert than the I-gel equivalent. These differences may not be clinically significant.

The randomized crossover comparison of airway sealing with the laryngeal mask airway Supreme(™) at three different intracuff pressures in children

BACKGROUND

An intracuff pressure of 80 cm H2 O in the adult-sized laryngeal mask airway Supreme has been recommended to obtain a higher oropharyngeal leak pressure (OLP). However, the intracuff pressure for the higher OLP in the pediatric laryngeal mask airway Supreme could be different from that in the adult-sized laryngeal mask airway Supreme. Thus, we measured and compared OLP at three intracuff pressures of 40, 60, and 80 cm H2 O in the pediatric laryngeal mask airway Supreme.

METHODS

This study was designed as a randomized crossover study and enrolled 36 children, aged 0-108 months and 5-30 kg in weight. After insertion of the laryngeal mask airway Supreme, oropharyngeal leak pressure (OLP) was measured at intracuff pressures of 40, 60, and 80 cm H2 O according to one of six sequences produced on the basis of 3 × 6 Williams crossover design. During the intraoperative period, the laryngeal mask airway Supreme was maintained using the last intracuff pressure of the allocated sequence. The intraoperative and postoperative complications were compared among three maintenance intracuff pressures.

RESULTS

OLP at the intracuff pressure of 60 cm H2 O was significantly higher than that of 40 cm H2 O (17.9 ± 3.9 vs 16.9 ± 4.2 cm H2 O, P = 0.004) and was comparable with that of 80 cm H2 O (17.9 ± 3.9 vs 17.8 ± 4.6 cm H2 O, P = 0.938). There were no significant differences of intraoperative and postoperative complications among the three maintenance intracuff pressures.

CONCLUSION

Our results suggest that the use of an intracuff pressure of 60 cm H2 O in pediatric laryngeal mask airway Supreme provides a higher OLP compared with 40 cm H2 O.

Comparison of i-gel supraglottic airway and LMA-ProSeal™ in pediatric patients under controlled ventilation

BACKGROUND

i-gel™ and the ProSeal™ laryngeal mask airway (PLMA) are two supraglottic airway devices with gastric channel used for airway maintenance in anesthesia. This study was designed to evaluate the efficacy of i-gel compared with PLMA for airway maintenance in pediatric patients under general anesthesia with controlled ventilation.

MATERIALS AND METHODS

A total of 60 American Society of Anesthesiologists physical status 1 and 2 patients were included in the study and randomized to either i-gel or PLMA group. After induction of anesthesia using a standardized protocol for all the patients, one of supraglottic airway devices was inserted. Insertion parameters, ease of gastric tube insertion and fiber-optic scoring of the glottis were noted. Airway parameters such as end-tidal carbon dioxide (EtCO2), peak airway pressures and leak airway pressures were noted. Patients were observed for any complications in the first 12 h of the post-operative period.

RESULTS

Both groups were comparable in terms of ease of insertion, number of attempts and other insertion parameters. Ease of gastric tube insertion, EtCO2, airway pressures (peak and leak airway pressure) and fiber-optic view of the glottis were comparable in both groups. There were no clinically significant complications in the first 12 h of the post-operative period.

CONCLUSION

i-gel is as effective as PLMA in pediatric patients under controlled ventilation.

Comparison of laryngeal mask airway supreme and laryngeal mask airway proseal for laryngopharyngeal trauma and postoperative morbidity in children

BACKGROUND AND OBJECTIVES

Laryngeal mask airway (LMA), which has been used frequently in airway management, can cause laryngopharyngeal injury and morbidity. In this trial, we compare the macroscopic changes on laryngopharyngeal structures and the postoperative laryngopharyngeal morbidity by using LMA supreme with LMA proseal in children.

METHODS

We divided patients into two groups. We inserted size three LMA proseal into the first group and size three LMA supreme into the second group. Before LMA insertion and after LMA removal, we performed direct laryngoscopy on the patients. We compared hyperemia, mucosal injury and blood staining on LMA removal, as well as insertion time, rate of success in gastric tube insertion on the first attempt, nausea, vomiting, and sore throat between the two groups.

RESULTS

We recorded no significant differences between the two groups for mean operation time, sex, age, weight, rate of success in gastric tube insertion on first attempt, nausea, vomiting, sore throat and mucosal injury. Mean insertion time for the LMA proseal group was significantly longer than the LMA supreme group (p = 0.0001). The ratio of blood staining on LMA removal was significantly higher in the LMA proseal group than the LMA supreme group (p = 0.034). The patients with blood staining on LMA removal exhibited significantly more mucosal hyperemia and injury than the patients with clear LMA (p = 0.0001, p = 0.020).

CONCLUSION

LMA supreme insertion is faster and easier than LMA proseal and causes less laryngopharyngeal injury than LMA proseal in children.

A randomized comparison of the laryngeal mask airway supreme™ and laryngeal mask airway unique™ in infants and children: does cuff pressure influence leak pressure?

BACKGROUND

The cuff pressure for optimal airway sealing with first-generation laryngeal mask airway has been shown to be 40 cm H(2)O in children. Currently, there are no data regarding the ideal intracuff pressure for the laryngeal mask airway Supreme (Supreme) in children.

OBJECTIVES

To compare the clinical performance of the laryngeal mask airway supreme with the laryngeal mask airway unique in infants and children.

MATERIALS AND METHODS

One hundred eighty children were assigned to receive either a Supreme or a laryngeal mask airway-U. We hypothesized higher airway leak pressure with the Supreme at both 40 cm H(2)O and 60 cm H(2)O, when compared with the laryngeal mask airway-U. Ease and time of insertion, insertion attempts, fiber optic examination, quality of airway, efficacy of mechanical ventilation, success of gastric tube placement (Supreme), incidence of gastric insufflation, and complications were also assessed.

RESULTS

Airway leak pressure at an intracuff pressure of 60 cm H(2)O for the Supreme was 17.4 (5.2) vs laryngeal mask airway-U at 18.4 (6.6) cm H(2)O and did not differ when compared to an intracuff pressure of 40 cm H(2)O for both devices; Supreme at 17.2 (5) vs laryngeal mask airway-U at 17.7 (6) cm H(2)O. The laryngeal mask airway-U was associated with higher first-attempt success rates. The Supreme was associated with less gastric insufflation than the laryngeal mask airway-U.

CONCLUSIONS

Intracuff pressures of 40 cm H(2)O may be sufficient for the Supreme in children, and there may be no added benefit of an intracuff pressure of 60 cm H(2)O, as leak pressures were similar. The Supreme may be preferred over the laryngeal mask airway-U for its lower rates of gastric insufflation and provision for gastric access when mechanical ventilation is utilized.

Comparison of ProSeal LMA with Supreme LMA in paediatric patients

BACKGROUND AND OBJECTIVE

Supreme laryngeal mask airway (S-LMA) has been improved in recent years, but comparative studies with a sizeable number of paediatric patients are limited in number. In this study, oropharyngeal leak pressures (OLPs) were compared between S-LMA and ProSeal laryngeal mask airway (P-LMA) in paediatric patients.

METHODS

After obtaining approval from the ethics committee and written informed consent from the relatives of the patients, 60 patients, from 9 months to 5 years of age and 10-20 kg in weight, who were recommended for elective surgery were included in this prospective and randomised study. The patients were assigned to the S-LMA and P-LMA groups. OLP, insertion times, success rates, ease of airway device placement, fibre optical assessment, success rates and insertion times of an orogastric tube (OGT) were compared.

RESULTS

P-LMA was placed successfully in all the patients. One patient was intubated in the S-LMA group. The outcomes of a total of 59 patients were analysed. The insertion times of the airway devices were shorter in the S-LMA group than in the P-LMA group (S-LMA; 12.2 ± 2.9, P-LMA; 15.4 ± 3.7 s) (P = 0.001). The first insertion attempts of airway device placement were similar. The OLPs were similar (P-LMA; 17.2 ± 2.3, S-LMA; 16.4 ± 1.7 cm H2 O). The fibre-optically determined anatomic position was better in the P-LMA group (P = 0.02). The insertion time of the OGT was shorter with S-LMA than with P-LMA (P = 0.01).

CONCLUSION

Our findings suggest that S-LMA has OLPs similar to those of P-LMA in paediatric patients and that S-LMA provides successful positive pressure ventilation.

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 randomized equivalence trial comparing the i-gel and laryngeal mask airway Supreme in children

BACKGROUND

The laryngeal mask airway Supreme (Supreme) is a new single-use supraglottic device with gastric access capability now available in all sizes for children.

OBJECTIVES

To compare the i-gel with the Supreme in children for routine airway maintenance.

MATERIALS/METHODS

One hundred and seventy children, aged 3 months to 11 years, 5-50 kg in weight, were randomly assigned to receive either the i-gel or the Supreme. The primary outcome measured was airway leak pressure. Secondary outcomes included the following: ease and time for insertion, insertion success rate, fiberoptic grade of view, ease of gastric tube placement, number of airway manipulations, quality of airway during anesthetic maintenance, and complications.

RESULTS

A total of 168 patients were assessed for the outcomes. The median (IQR [range]) airway leak pressure for the i-gel was higher than with the Supreme, 20 (18-25 [9-40]) cm H(2)O vs 17 (14-22 [10-40]) cm H(2)O, respectively (P = 0.001). There were no differences in the time for device insertion, fiberoptic grade of view, quality of airway, and complications. Median (IQR[range]) time of successful insertion of a gastric tube was faster with the Supreme, 12 (9.2-14.3 [5.2-44.2]) s than with the i-gel, 14 (11.9-19 [6.9-75]) s; P = 0.01. The number of airway manipulations during placement was higher with the i-gel than with the laryngeal mask airway Supreme (12 vs 13 patients), P = 0.02.

CONCLUSIONS

In infants and children, when a single-use supraglottic device with gastric access capabilities is required, the i-gel demonstrated higher airway leak pressures and can be a useful alternative to the Supreme.

Pediatric airway management: current practices and future directions

Management of a pediatric airway can be a challenge, especially for the non-pediatric anesthesiologists. Structured algorithms for an unexpected difficult pediatric airway have been missing so far. A recent step wise algorithm, based on the Difficult Airway society (DAS) adult protocol, is a step in the right direction. There have been some exciting advances in development of pediatric extra-glottic devices for maintaining ventilation, and introduction of pediatric versions of new 'non line of sight' laryngoscopes and optical stylets. The exact role of these devices in routine and emergent situations is still evolving. Recent advances in simulation technology has become a valuable tool in imparting psychomotor and procedural skills to trainees and allied healthcare workers. Moving toward the goal of eliminating serious adverse events during the management of routine and difficult pediatric airway, authors propose that institutions develop a dedicated Difficult Airway Service comprising of a team of experts in advanced airway management.