A Comparison of the End-Tidal Sevourane Concentration for Removal of the Laryngeal Mask Airway and Laryngeal Tube in Anesthetized

Children
Jeong-Rim Lee, MD Young-Sun Lee, MD Chong Sung Kim, MD, PhD Seong Deok Kim, MD, PhD Hee-Soo Kim, MD, PhD
BACKGROUND: In this study we quantified and compared the optimal sevoflurane concentration required to prevent coughing or moving during or after removal of the laryngeal mask airway (LMA) and the laryngeal tube (LT) in anesthetized children. METHODS: Forty unpremedicated children, aged 8 mo to 12 yr, were randomly allocated to receive the LMA or LT. General anesthesia was induced via mask with sevoflurane and the LMA or LT was inserted. Anesthesia was maintained with sevoflurane and oxygen. At the end of surgery, a predetermined end-tidal sevoflurane concentration was maintained for at least 10 min and the LMA or LT was removed. Using Dixons up-down method, the concentration for LMA and LT removal was determined by adjusting the dose by a 0.2% increment. Success was defined by the absence of coughing, teeth clenching, gross purposeful movement, breath holding, laryngospasm, and desaturation. RESULTS: The end-tidal concentration of sevoflurane to achieve successful LMA removal in 50% of children was 1.90%, in 95% of children was 2.15%. For the LT, the concentrations were 1.83% and 2.00%. The 50% effective dose values did not differ significantly between groups. CONCLUSIONS: LMA and LT removal in 95% of anesthetized children (aged 8 mo to 12 yr) can be safely accomplished without coughing, moving, or any other airway complications at 0.86 and 0.80 minimum alveolar anesthetic concentration, respectively, and a similar concentration should be used for removal of the LT or LMA in children.
(Anesth Analg 2008;106:11225)

he laryngeal mask airway (LMA, Laryngeal Mask Company, Heney-on-Thames, UK) and laryngeal tube (LT, VBM Medizintechnik, Sulz, Germany) are supraglottic devices for securing the airway. They allow for rapid provision of a patent airway with few complications.1,2 In selected conditions in children, the incidence of coughing, biting, hypersalivation, and hypoxia might be decreased when the LMA is removed with the patient anesthetized rather than awake.3,4 Currently there are no data about the minimum sevoflurane concentration required for the removal of the LT in children. Because, by structural design, the inflatable balloons of the LMA and LT are in contact with different regions of the laryngopharyngeal area,5 the optimal
From the Department of Anesthesiology, Seoul National University College of Medicine, Seoul, Korea. Accepted for publication July 26, 2007. Jeong-Rim Lee and Young-Sun Lee are equally contributed in this study. Address correspondence and reprint requests to Hee-Soo Kim, MD, PhD, Department of Anesthesiology, Seoul National University College of Medicine, Seoul, Korea, # 28 Yongondong, Jongrogu, Seoul, Korea. Address e-mail to dami0605@snu.ac.kr. Copyright 2008 International Anesthesia Research Society
DOI: 10.1213/01.ane.0000286174.07844.e9

required sevoflurane concentrations for safe removal of a LMA and LT might be different. This study was designed to evaluate and compare the optimal sevoflurane concentration required for the safe removal of these two airway devices in children.

METHODS
After hospital ethics committee approval and informed written consent from the parents were obtained, 40 children, aged 8 mo to 12 yr, ASA Class III, scheduled for minor urologic (hydrocelectomy, orchiopexy, or circumcision), plastic (polydactyly division or skin graft), and orthopedic surgery (foreign body removal or closed reduction of fracture) were enrolled in this prospective, randomized study. Patients with an abnormal airway, reactive airway disease, or a history of respiratory tract infection in the preceding 6 wk were excluded. All surgical procedures were scheduled to be less than 2 h. All the children were unpremedicated. Upon arrival at the operating room, patients were monitored with electrocardiography, pulse oximetry, and noninvasive arterial blood pressure. Inspired and expired end-tidal sevoflurane concentrations were monitored and recorded (Solar 8000M, GE, Milwaukee, WI).
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Anesthesia was induced by inhalation of 8% sevoflurane in oxygen using a pediatric circle system. After loss of consciousness, sevoflurane was reduced and adjusted to 2%3% end-tidal concentration; the patients heart rate and arterial blood pressure were maintained within 20% of the preoperative values and the jaw was adequately relaxed (Muzi score 1 or 2)6 to allow for LMA or LT insertion. The decision to insert either a LMA or LT was based on random numbers sampling tables. The LMA and LT size for each patient was determined from the manufacturers guidelines and chosen according to the patients body weight or height: LMA size 2 for 6.520 kg, size 2.5 for 20 30 kg, and size 3 for 30 50 kg; LT size 1 for 12 kg, 2 for 1225 kg, and LT suction 2.5 for 25 kg or 155 cm. We attempted insertion of a LMA or LT less than three times in all patients. The cuffs of the LMA or LT were inflated with a syringe and the intracuff pressure was adjusted to 60 cm H2O. The concentration of sevoflurane was adjusted in response to clinical signs during the maintenance phase of anesthesia. The patients breathed spontaneously and the anesthesiologist assisted their ventilation intermittently to adjust end-tidal carbon dioxide between 35 and 45 mm Hg. After the surgery was completed, the oropharynx was gently suctioned before the depth of anesthesia was changed. The inspired sevoflurane concentration was adjusted to the predetermined concentration and maintained until the same concentration of expired end-tidal sevoflurane concentration was attained. The predetermined concentration was maintained for at least 10 min to allow equilibrium between the alveolar and brain concentrations. The LMA or LT was then removed. The LMA was removed with cuff inflated,7 whereas the LT was removed with cuff deflated, as per manufacturers recommendation. The concentration of sevoflurane delivered during airway device removal was determined by the previous patients response to airway device removal. The Dixons up-and-down method was used using 0.2% step increments.8 The initial patients received 2% sevoflurane, because in a previous study the 95% effective dose (ED95) for removal of a LMA was 2.17% sevoflurane.8 LMA or LT removal was classified as an unsuccessful removal if complications such as coughing, teeth clenching, gross purposeful movements, breath holding, laryngospasm, or desaturation to a Spo2 90% occurred either during or within 1 min of device removal. An unsuccessful removal of the device resulted in increasing the sevoflurane concentration by 0.2% for the next patient. If the device removal was successful (i.e., without complication), the sevoflurane concentration for the next patient was decreased by 0.2%. After LMA or LT removal, patients were managed by an anesthesiologist and transferred to the recovery room until they became fully awake. The Dixons up-and-down method requires six pairs of failure-success for statistical analysis.9 ED50
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Table 1. Patients Characteristics and Duration of LMA Insertion LMA LT

Male/Female 12/6 13/9 Age (yr) 5 (0.712) 5 (0.8412) Weight (kg) 17.5 (936.4) 16.8 (940.5) Height (cm) 104.1 (70.6154.9) 105.2 (75.6155.5) Duration of insertion 85 (55130) 90 (40135) (min)
Values are expressed as median (range). Duration of insertion refers to the elapsed time the patient maintained in the laryngeal mask airway (LMA) or laryngeal tube (LT) insertion state.

Figure 1. Dixons up and down method; assessment of failure or success for device removal. Success or failure for laryngeal mask airway (LMA) or laryngeal tube (LT) removal is defined in the text. A circle represents each patients data. was calculated with averaging the mid-point concentration of all independent pairs of patients involving a crossover. The ED50 and ED95 were estimated using the probit model10 and comparisons of the values in log scale between the two groups were performed. A P value 0.05 was considered significant. A logistic regression analysis was used to obtain the probability of smooth removal of a LMA or LT versus end-tidal sevoflurane concentration.

RESULTS
The patients characteristics and the duration of LMA or LT insertion were similar (Table 1). The sequences of successful and unsuccessful LMA or LT removal are shown in Figure 1. The ED50 of sevoflu 2008 International Anesthesia Research Society

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the LT or LMA groups was not significantly different, and the incidence of complications was similar in older and younger patients.

DISCUSSION
Our study might be the first to report the optimal sevoflurane concentration for safe LT removal. Interestingly, sevoflurane concentrations for safe removal of a LMA and LT without airway irritation were similar. The indications for LMA and LT use are similar; however, differences in the cuff portion of both devices might result in different anesthetic requirements during clinical use, i.e., insertion, maintenance, and removal periods. When inserting a LMA and LT in adults, the propofol concentration for LT insertion was less than that for a LMA, and the authors explained that the easier insertion method of a LT seemed to cause less oropharyngeal stimulation than a LMA.11 Differences in structural design with the LT having better oropharyngeal sealing and/or less gastric insufflation 12 or easy insertion due to its narrow width13 have also been offered as an explanation. Therefore, it is thought that differences in cuff size might result in a different degree of stimulation during emergence from anesthesia. In our study, however, there was no difference in the optimal sevoflurane concentration for the removal of the LT and LMA device in children. The absence of differences in anesthetic requirement for removal of the devices could be explained by the fact that both devices are in contact with the esophageal inlet and result in similar levels of stimulation. Another possibility is that the devices are removed differently. The LMA was removed with the cuff inflated,7 whereas the LT was removed with the cuff deflated, as per manufacturers recommendation. However, removal conditions used in this study are commonly applied in daily practice. In the clinical use of LMA or LT in pediatrics, therefore, the anesthetic depth required for removal of each device without provoking airway stimulation would be almost the same. Although the anesthetic depth for device removal was the same, the complications in LT or LMA removal were different. There were fewer complications such as breath holding or laryngospasm in unsuccessful removals in the LT group than LMA group. In our study, complications occurred because the anesthetic depth was not enough to suppress the airway reflex; therefore, the anesthesiologist should consider the possibility of airway complications during a light anesthetic state. In conclusion, we found that LMA removal in 50% and 95% of anesthetized children, aged from 8 mo to 12 yr, can be safely accomplished at end-tidal sevoflurane concentrations of 1.90% and 2.15%. For LT, the concentrations are 1.83% and 2.00%. Safe
ANESTHESIA & ANALGESIA

Figure 2. Dose-response curve for sevoflurane plotted from the probit analysis of individual end-tidal concentrations and the respective reactions to the removal of laryngeal mask airway (LMA) and laryngeal tube (LT) in children. Table 2. The Number of Each Adverse Response in Patients with Unsuccessful Removal LMA (n 9)
Cough Teeth clenching Movement Breath holding Laryngospasm Desaturation (Spo2
LMA

(n

LT 11)
0 2 11 0 0 0

90%)
laryngeal tube.

1 2 5 3 3 0

laryngeal mask airway; LT

rane for LMA and LT removal was 1.90% and 1.83% sevoflurane, and the ED95 for smooth removal was 2.15% and 2.00%, respectively. The logistic regression curve of the probability of smooth removal for both groups is shown in Figure 2. The ED50 and ED95 to the minimum alveolar anesthetic concentration (MAC) ratio of sevoflurane for LMA removal were 0.76 and 0.86 and those for LT removal were 0.72 and 0.80, respectively. We compared the ED50 values, in log scale, between the two groups. The result of testing the difference between the groups suggested a nonstatistically significant P value of 0.9794. The result for the ED95 was also similar (P 0.9749). The complications in patients with unsuccessful removal are presented in Table 2. Laryngospasm occurred in three patients with the LMA (one at 1.6%, two at 1.8% of sevoflurane), and all three patients were easily treated with assisted positive-pressure ventilation with 100% oxygen. There were no episodes of breath holding or laryngospasm in the LT group. Other complications associated with unsuccessful removal resolved spontaneously without specific management. We compared the ages between success and failure for each device. The median age of patients with failed and successful removal of the LT was 5.0 and 5.5 yr, respectively, whereas the median age of failed and successful LMA removal was 4.4 and 5.2 yr, respectively. The age between success and failure in
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Sevoflurane Concentration for Removal of LMA or LT

LMA and LT removal in children receiving sevoflurane may be possible at approximately 0.86 and 0.80 MAC, respectively. ACKNOWLEDGMENTS This study was supported by SNUH fund (0520040040). REFERENCES
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6. Muzi M, Robinson BJ, Ebert TJ, OBrien TJ. Induction of anesthesia and tracheal intubation with sevoflurane in adults. Anesthesiology 1996;85:536 43 7. Deakin CD, Diprose P, Majumdar R, Pulletz M. An investigation into the quantity of secretions removed by inflated and deflated laryngeal mask airways. Anaesthesia 2000;55:478 80 8. Lee JR, Kim SD, Kim CS, Yoon TG, Kim HS. Minimum alveolar concentration of sevoflurane for laryngeal mask airway removal in anesthetized children. Anesth Analg 2007;104:528 31 9. Dixon WJ. Staircase bioassay: the up-and-down method. Neurosci Biobehav Rev 1991;15:4750 10. Christopher J. Statistical analysis of categorical data. 1st ed. New York, NY: John Wiley & Sons Canada, Ltd, 1999 11. Richebe P, Rivalan B, Baudouin L, Sesay M, Sztark F, Cros AM. Comparison of the anaesthetic requirement with targetcontrolled infusion of propofol to insert the laryngeal tube vs. the laryngeal mask. Eur J Anaesthesiol 2005;22:858 63 12. Asai T, Kawashima A, Hidaka I, Kawachi S. The laryngeal tube compared with the laryngeal mask: insertion, gas leak pressure and gastric insufflation. Br J Anaesth 2002;89:729 32 13. Asai T, Matsumoto S, Shingu K, Noguchi T, Koga K. Use of the laryngeal tube after failed insertion of a laryngeal mask airway. Anaesthesia 2005;60:825 6

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