Laryngeal mask vs. laryngeal tube trial in paediatric patients (LaMaTuPe): a single-blinded, open-label, randomised-controlled trial

BACKGROUND

In hypoxemic children with difficult airway, or for minor elective procedures, the use of a supraglottic airway device may be preferred to endotracheal intubation, whether with a laryngeal mask or laryngeal tube. Second-generation laryngeal masks may offer a better safety profile. Whether they should be preferred to laryngeal tubes is unknown. This study aimed to compare the efficacy and safety of second-generation laryngeal masks and laryngeal tubes in children.

METHODS

This randomised-controlled trial was conducted in a single university hospital in children <18 years undergoing elective anaesthesia in urology, minor paediatric surgery and gynaecology. Patients were 1 : 1 randomised to the laryngeal mask or laryngeal tube group. Children were allocated a second-generation laryngeal tube or a second-generation laryngeal mask as the primary airway device. The primary endpoint was insertion time. Secondary endpoints included first-attempt success, overall success and complications, which included hypoxia (SpO2 < 90%), laryngospasm, bronchospasm, aspiration and bleeding.

RESULTS

In total, 135 patients were randomised, with 61 allocated to the laryngeal tube and 74 to the laryngeal mask group, with a median age of 5.4 and 4.9 years, respectively. Median insertion time was significantly longer in the laryngeal tube group (37 vs. 31 s; difference of medians: 6.0 s; 95% confidence interval: 0.0-13.0). The laryngeal tube had a significantly lower first-attempt (41.0%) and overall success rate (45.9%) than the laryngeal mask (90.5% and 97.3%, respectively). Those allocated to the laryngeal tube group had a higher ratio of complications (27.8%) compared to the laryngeal mask group (2.7%).

CONCLUSION

This randomised-controlled trial reported that in children undergoing elective anaesthesia, the use of a laryngeal tube was associated with a longer insertion time.

[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.

Utility of the gastro-laryngeal tube during transesophageal echocardiography: A prospective randomized clinical trial

BACKGROUND

To validate the utility and performance of the gastro-laryngeal tube (GLT) in terms of cardiologist and patient satisfaction levels, incidence of and attempts at successful transesophageal echocardiography (TEE) probe placement, perioperative and postoperative hemodynamics, and adverse events related to the TEE procedure.

METHODS

In this randomized prospective clinical study, forty-four patients undergoing TEE and aged 20 to 80 years old scheduled for TEE were randomly allocated to two study groups: Group SA (sedation and analgesia) and Group GLT. Cardiologist and patient satisfaction levels, TEE probe placement performance, hemodynamics, adverse events related to the TEE procedure, demographic characteristics, and TEE procedure data were recorded.

RESULTS

The cardiologist satisfaction level was significantly higher in Group GLT (P = .011). The TEE probe was successfully placed at the first attempt in all the patients in Group GLT and at the first attempt in 11 patients, at the second attempt in 8 patients, and at the third attempt in 3 patients in Group SA. The TEE probe placement success was significantly higher in Group GLT (P < .001), and TEE probe placement was significantly easier in Group GLT (P < .001). There were no significant differences in patient satisfaction, heart rate, mean arterial pressure, oxygen saturation, adverse events related to the TEE procedure between the groups.

CONCLUSION

The present study revealed that GLT use elicited a higher cardiologist satisfaction level and resulted in more successful and easier TEE probe placement. We thus conclude that the use of the recently developed GLT may ensure airway management safety and a comfortable TEE experience.

Cobra-PLA provides higher oropharyngeal leak pressure than LMA-Classic and LMA-Unique: A meta-analysis with 22 studies

Cobra Perilaryngeal Airway (Cobra-PLA) is a relatively new single-use supraglottic device employed during general anesthesia. This meta-analysis includes randomized controlled trials (RCTs) yielding extensive comparison results among Cobra-PLA, Laryngeal Mask Airway (LMA)-Classic, and LMA-Unique.Two authors performed searches in EMBASE, CENTRAL, PubMed, and ScienceDirect to identify RCTs that compared Cobra-PLA with LMA-Classic and with LMA-Unique in patients undergoing general anesthesia. Both random- and fixed-effects models were used. Begg's funnel plot was used to evaluate publication bias.Twenty-two RCTs with a total of 1845 patients were included. Cobra-PLA offered significantly higher oropharyngeal leak pressure than LMA-Classic [mean difference (MD) = 3.56 (1.56, 5.55), P = .0005] and LMA-Unique [MD = 4.44 (2.12, 6.76), P = .0002]. First-insertion success rate, ease of insertion, insertion time, and reported complications among Cobra-PLA, LMA-Classic, and LMA-Unique were similar.Compared with the commonly used LMA-Classic and LMA-Unique, Cobra-PLA provides superior airway sealing.

Comparison Between the Cobra Perilaryngeal Airway and Laryngeal Mask Airways Under General Anesthesia: A Systematic Review and Meta-analysis

The complication rate and efficacy of the Cobra Perilaryngeal Airway (CobraPLA) and laryngeal mask airways (LMAs®) have been evaluated in the published literature, but the conclusions have been inconsistent. The aim of this systematic review and meta-analysis was thus to assess the performance of the CobraPLA and LMAs under general anesthesia. We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials comparing the CobraPLA with LMAs under general anesthesia. The LMAs used for comparison were the classic LMA (CLMA) and the unique LMA (ULMA). The random effect model was used if heterogeneity was observed, otherwise the fixed effect model was used. Seventeen randomized controlled trials were included; number of studies analyzed for each result are different and were up to 10. The current result suggests that no significant difference between the devices in the insertion success rate at the first attempt. The success rate of first insertion of the CobraPLA was not different from the rates for the CLMA and the ULMA (relative risk: 0.95, 95% confidence interval [CI], 0.91-1.00). CobraPLA insertion was not different from CLMA and ULMA insertion. The CobraPLA provided an oropharyngeal leak pressure higher than that provided by the CLMA (weight mean difference: 3.90, 95% CI, [1.59-6.21] cmH2O) and ULMA (weight mean difference: 6.57, 95% CI, [4.30-8.84] cmH2O). We also found a higher likelihood of blood staining in the airway with the CobraPLA than with the CLMA. In our research, the principal finding of our meta-analysis is that the success rate of first insertion of the CobraPLA was not different from the rate for each of the CLMA and the ULMA, which featured a short learning curve implying its ease of insertion. There was also no significant difference in the incidence of the best view (with a score of 4) obtained with the CobraPLA compared with the other 2 devices. The CobraPLA does seem to be superior to the CLMA and ULMA in providing a higher oropharyngeal leak pressure. The data were insufficient to establish differences in airway adverse events between the groups except for blood staining in the devices, although mucosal trauma occurred more frequently with the Cobra PLA device than with the CLMA and the ULMA.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Alternative airways for the pediatric emergency department

Securing the pediatric airway in the emergency setting is an uncommon event that is complicated by anatomic, physiologic, and environmental factors. Even more uncommonly, practitioners are faced with the added complication of a difficult airway, and the question of what alternatives to traditional endotracheal intubation are available and most useful may arise. Timely and effective intervention determines the patient's clinical outcome. The purpose of this review was to detail specific alternative airway management strategies and tools for use in the pediatric emergency department.

Laryngeal mask airway vs the endotracheal tube in paediatric airway management: A meta-analysis of prospective randomised controlled trials

A meta-analysis was performed on prospective randomised controlled trials to assess whether the laryngeal mask airway (LMA) offered any advantage over the conventional endotracheal tube in the paediatric age group. Using the Cochrane methodology, a literature search was carried out through peer-reviewed indexed journals in three medical databases to obtain all publications comparing the LMA with the endotracheal tube in the paediatric age group (age less than 12 years), available till December 2010. Data from 16 randomised controlled clinical trials were selected for analysis. A null hypothesis was formed against each of the seven issues tested using the Fisher's method of combining P values. The LMA was seen to have three advantages over the tracheal tube in the form of lower incidence of cough during emergence, lower incidence of postoperative sore throat and lower incidence of postoperative vomiting (P<0.05). It was seen to offer no advantage over the tracheal tube in incidence of bronchospasm or laryngospasm during emergence; also, it did not offer any advantage in increasing the efficacy of the airway seal. The only disadvantage the LMA had over the tracheal tube was its greater incidence of placement failure in the first attempt.