Comparison of laryngeal mask airway vs tracheal intubation: a systematic review on airway complications

doi:10.1016/j.jclinane.2016.10.004

Journal of Clinical Anesthesia

Volume 36, February 2017, Pages 142-150

https://doi.org/10.1016/j.jclinane.2016.10.004 Get rights and content

Highlights

•
Postoperative airway complications after laryngeal mask airway (LMA) and tracheal tube.
•
There is no clear difference in postoperative airway complications.
•
The LMA Supreme is related to the lowest incidence of airway complications.
•
Heterogeneity restricts pooling of data.
•
Future trials are needed to objectify the possible advantages of the LMA.

Abstract

To determine whether the laryngeal mask airway (LMA) has advantages over the tracheal tube (TT) in terms of incidence of cough, sore throat, laryngospasm, dysphagia, dysphonia, and blood staining. This is a systematic literature review performed at the Universtity Medical Center of Utrecht. The online databases PubMed, Embase, and the Cochrane Library were searched for relevant randomized controlled trials. Two independent reviewers selected relevant articles after title, abstract, and full text screening. Articles were assessed on risk of bias in accordance with the Cochrane risk of bias tool. Study results of the LMA and the TT were related to the method of selection of the device size and the method for cuff inflation. Of the 1718 unique articles, we included 19 studies which used the LMA Classic, the LMA Proseal, the Flexible Reinforced LMA, and the LMA Supreme compared with TT. After methodological inspection, data could not be pooled due to heterogeneity among the selected studies. Overall, no clear advantage of the LMA over the TT was found but the LMA Supreme was related to the lowest incidence of airway complications. In this review, no clear difference in incidence of postoperative airway complications could be demonstrated between LMA and TT. The LMA Supreme may reduce the incidence of airway complication in comparison to the TT but high quality randomized trials are recommended to further objectify if use of the LMA decreases the risk on postoperative airway complications.

Introduction

The laryngeal mask airway (LMA) was introduced in 1988 in the United States [1], [2]. The LMA gained wide acceptance as an alternative to traditional tracheal tube (TT) intubation due to ease of insertion and a possible lower risk of trauma to the trachea [3], [4]. However, for surgical procedures requiring muscle relaxation, mechanical positive-pressure ventilation is required to secure airway ventilation. To achieve PPV with an LMA, a higher cuff pressure can be used but this does not provide an airtight seal and creates a risk of regurgitation and pulmonary aspiration [5], [6]. Obesity, laparoscopic surgery, and gastroesophageal reflux may be relative contraindication for the use of LMA. Second-generation supraglottic airway devices have been introduced enabling a higher positive pressure, reducing the risk of aspiration, and lowering the risk on respiratory complications. Continuously, the advantages and disadvantages of LMA and the TT concerning the incidence of airway complications are debated in literature [7], [8]. So far, there is no consensus on the advantage of a single device concerning complications on the direct surrounding tissues related to the type of ventilation technique such as cough, sore throat, laryngospasm, dysphagia, dysphonia, or blood on device. A meta-analysis concluded that the LMA is related to a lower risk on several postoperative airway complications when compared with the TT but the selection and handling of the device were not taken in account [7]. Significant risk factors for postoperative airway complications related to the use of LMA or TT, such as proper device size to patient size and the cuff volume, are of influence when interpreting study findings. With this systematic review, we aim to investigate the risk on airway complications in adult patients after general anesthesia comparing LMA and TT taken risk factors as device size and cuff pressure into account.

Section snippets

Materials and methods

We performed a systematic search in PubMed, Embase, and the Cochrane Library (the Cochrane Collaboration's Register of Clinical Trials) in August 2015; this was updated in September 2016. Relevant synonyms included “laryngeal mask,” “laryngeal mask airway,” “LMA,” “endotracheal,” “intubation,” and “intratracheal” (see details on search strategy in Appendix 1). In addition, PubMed and Web of Science were searched for related articles, and references of the selected articles were handsearched for

Results

The initial search yielded 2797 titles, of which 1718 unique studies were screened. We manually searched all these articles for eligibility whereas 109 were selected for full text screening. Cross-reference checking revealed no additional relevant articles. A total of 19 articles compared LMA or an LMA subtype with TT. The individual study characteristics are shown in Table 1. Results after the risk of bias assessment are shown in Table 2. In all 19 studies [12], [13], [14], [15], [16], [17],

Explanation of results

The principal aim of this systematic review was to compare the incidence of airway complications after LMA ventilation, including several subtypes, compared with TT ventilation after general anesthesia. After we selected studies which used a clear method for selecting the size of the device and cuff inflation into account, 8 [12], [13], [18], [20], [22], [24], [27], [28] studies could be selected. Compared with TT, we found comparable incidence rates for sore throat after use of the LMA Classic

Authors Contribution

BFE, writing, data collection, data analysis, interpretation, drafting and revision, approval of final version; IS, data collection, data analysis, interpretation, drafting and revision, approval of final version; ALS, design, drafting and revision, approval final version, supervision.

Acknowledgments

The authors thank B Kramer, PhD and P Wiersma medical sciences specialists at Utrecht University Library for their help to develop the search strategy.

References (32)

A.I. Brain
The laryngeal mask—a new concept in airway management
Br J Anaesth
(1983)
J.R. Brimacombe et al.
The incidence of aspiration associated with the laryngeal mask airway: a meta-analysis of published literature
J Clin Anesth
(1995)
C.V. Pollack
The laryngeal mask airway: a comprehensive review for the emergency physician
J Emerg Med
(2001)
S.J. Yu et al.
Laryngeal mask airways have a lower risk of airway complications compared with endotracheal intubation: a systematic review
J Oral Maxillofac Surg
(2010)
N.M. Woodall et al.
National census of airway management techniques used for anaesthesia in the UK: first phase of the Fourth National Audit Project at the Royal College of Anaesthetists
Br J Anaesth
(2011)
M. Hohlrieder et al.
Postoperative nausea, vomiting, airway morbidity, and analgesic requirements are lower for the ProSeal laryngeal mask airway than the tracheal tube in females undergoing breast and gynaecological surgery
Br J Anaesth
(2007)
B. Hartmann et al.
Laryngeal mask airway versus endotracheal tube for outpatient surgery: analysis of anesthesia-controlled time
J Clin Anesth
(2004)
G.P. Joshi et al.
Work of breathing in anesthetized patients: laryngeal mask airway versus tracheal tube
J Clin Anesth
(1998)
A. Rieger et al.
Laryngo-pharyngeal complaints following larngeal mask airway and endotracheal intubation
J Clin Anesth
(1997)
S.R. Barreira et al.
Prospective randomized clinical trial of laryngeal mask airway Supreme® used in patients undergoing general anesthesia
Rev Bras Anestesiol
(2013)

J. Brimacombe

The advantages of the LMA over the tracheal tube or facemask: a meta-analysis

Can J Anaesth

(1995)

A. Nicholson et al.

Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients

Cochrane Database Syst Rev

(2013)

A. Macario et al.

A cost analysis of the laryngeal mask airway for elective surgery in adult outpatients

Anesthesiology

(1995)

J.P.T. Higgins et al.

The Cochrane Collaboration's tool for assessing risk of bias in randomised trials

BMJ

(2011)

D. Moher et al.

Preferred reporting items for systematic reveiws and meta-analyses:the PRISMA statement

PLoS Med

(2009)

M. Hohlrieder et al.

A study of airway management using the ProSeal LMA laryngeal mask airway compared with the tracheal tube on postoperative analgesia requirements following gynaecological laparoscopic surgery

Anaesthesia

(2007)

Cited by (71)

Laryngeal mask: Under-exploited potential
2024, Praticien en Anesthesie Reanimation
Les masques laryngés sont des dispositifs mis au point depuis 40 ans. Ils sont largement introduits dans la pratique courante mais restent encore sous-utilisés en France en raison de freins psychologiques sans rationnel scientifique. Le but de cette mise au point est d’offrir un aperçu des avantages et inconvénients liés à l’utilisation de ces dispositifs et, à l’aide d’une revue de la littérature, de déconstruire certaines contre-indications qui n’ont pas lieu d’être : cœlioscopie, patient obèse, positions peropératoires variées et chirurgies prolongées…
Laryngeal masks are devices commonly used for the past 40 years, but are still under-exploited in France due to psychological barriers with non or low scientific rational. The aim of this article is to provide an overview of the advantages and drawbacks of laryngeal masks, and, with the support of a literature review, to deconstruct unjustified contraindications: laparoscopy, obese patients, variable intraoperative positions and prolonged surgical procedures…
Comparison of laryngeal mask airway (LMA) insertion with and without muscle relaxant in pediatric anesthesia; a randomized clinical trial
2022, Heliyon
Citation Excerpt :
The LMA does not compel a laryngoscope to visualize the glottis, so it is implausible to manipulate or damage the larynx [1, 2, 3]. The application of LMA is very advantageous for keeping the airway open and is usually applied in outpatient and short surgeries in adults and children under general anesthesia [4, 5]. In fact, there is no need to enter the trachea and cardiovascular stimulation [6].
This study aimed to evaluate the effectiveness of using muscle relaxant on the ease of laryngeal mask airway (LMA) insertion and possibility of its related complications.
This double-blind, randomized clinical trial was performed on 60 children aged 1–4 years with ASA (American Society of Anesthesiology) I or II with upper limb injuries who were candidates for surgery. The patients were randomly allocated to the two groups receiving atracurium group as muscle relaxant (MR) or saline group (S).
Regarding ease of placement, the LMA was inserted in 66.7% and 63.3% of patients straightforwardly in the MR and S groups, respectively. While it was performed with one maneuver in 23.3% and 26.7% of cases in the MR and S groups, respectively (p = 0.955). Moreover, LMA dislodgment in the two groups was 36.7% in the MR group and 20.0% in the S group without a meaningful difference (P = 0.152). The only complication observed in the two groups was laryngospasm, which occurred in 0.10% and 13.3% in the MR and S groups, respectively (p = 0.688).
In some pediatric anesthesia, the use of atracurium, as a muscle relaxant had no significant effect on capability of LMA insertion, maintaining airway patency, LMA seal pressure and oxygenation variations. Moreover, it did not have a preventive effect on the occurrence of complications such as laryngospasm.
Pharyngolaryngeal Morbidity With the Laryngeal Mask Airway Supreme<sup>TM</sup> at Different Fiberoptic Bronchoscopy Grades: An Observational Study
2022, Journal of Voice
Citation Excerpt :
However, minor and common PLMs still cause significant distress to patients and decrease their postoperative satisfaction.2-5 Laryngeal mask airway (LMA) SupremeTM (Teleflex Medical, Athlone Co., Westmeath, Ireland) is an SAD with an inflatable cuff and two lumens,6 and the incidence of PLM is significantly lower in LMA SupremeTM than in other SADs.7,8 Researchers have attempted to identify various factors that cause PLM, such as the LMA size, technique of insertion, varying intracuff pressures, choice of gas used to inflate the cuff, mode of ventilation and use of pharmacological agents.9-12
To assess whether the different fiberoptic bronchoscopy (FOB) grades of laryngeal mask airway (LMA) Supreme™ affects pharyngolaryngeal morbidity (PLM, including sore throat, dysphonia, pharyngoxerosis, and dysphagia) after general anesthesia.
A total of 235 adult patients scheduled for elective laser lithotripsy undergoing general anesthesia with the placement of LMA Supreme™ were enrolled. The position of LMA Supreme™ was assessed by FOB and categorized into five grades. Meanwhile, patients were divided into four groups (grades A–D); none was assessed as grade E. We collected blinded data on PLM at 2 (H+2), 6 (H+6), and 24 hours (H+24) postoperatively. The incidence and severity of PLM as the primary outcome and incidence of PLM at three time points as a secondary outcome were compared.
The incidence of PLM was higher at 2 and 6 hours than at 24 hours; however, no significant difference was found between the incidence of PLM in the FOB groups. Furthermore, the severity of sore throat and dysphonia between groups were obviously differed at H+6 and H+24, but similar at H+2. The severity of postoperative pharyngoxerosis and dysphagia were similar between groups at three time points.
A positive association was found between the severity of postoperative sore throat and dysphonia and FOB grade after LMA Supreme™ placement. PLM secondary to placement of the LMA Supreme™ was short lasting.
Laryngeal Mask Airway Versus Endotracheal Intubation during Lacrimal Duct Stenosis Surgery in Children—A Retrospective Analysis
2024, Children
Comparison of Two Methods With a Left-Sided Double-Lumen Tube for Endobronchial Intubation
2024, Acta Academiae Medicinae Sinicae
Pre-operative gastric ultrasound in patients at risk of pulmonary aspiration: a prospective observational cohort study
2023, Anaesthesia

View all citing articles on Scopus

^☆: Competing interest: No external funding and no competing interests declared.

¹: University Medical Center Utrecht, Department of Otorhinolaryngology, Head and Neck Surgery, Heidelberglaan 100, 3508 AB Utrecht, The Netherlands. Tel.: +31 88 75 55 8375.

View full text

ReviewComparison of laryngeal mask airway vs tracheal intubation: a systematic review on airway complications☆

Highlights

Abstract

Introduction

Section snippets

Materials and methods

Results

Explanation of results

Authors Contribution

Acknowledgments

Br J Anaesth

J Clin Anesth

J Emerg Med

J Oral Maxillofac Surg

Br J Anaesth

Br J Anaesth

J Clin Anesth

J Clin Anesth

J Clin Anesth

Rev Bras Anestesiol

The advantages of the LMA over the tracheal tube or facemask: a meta-analysis

Can J Anaesth

Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients

Cochrane Database Syst Rev

A cost analysis of the laryngeal mask airway for elective surgery in adult outpatients

Anesthesiology

The Cochrane Collaboration's tool for assessing risk of bias in randomised trials

BMJ

Preferred reporting items for systematic reveiws and meta-analyses:the PRISMA statement

PLoS Med

A study of airway management using the ProSeal LMA laryngeal mask airway compared with the tracheal tube on postoperative analgesia requirements following gynaecological laparoscopic surgery

Anaesthesia

Review
Comparison of laryngeal mask airway vs tracheal intubation: a systematic review on airway complications☆