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19 (Suppl. 1): 55–65
A critique of elective pediatric supraglottic airway devices
M I C H E L L E C . W H I TE PETER A. STODDART
DCH FRCA*, MRCP FRCA*
TIM M. COOK
*Consultant Paediatric Anaesthetist, Bristol Royal Hospital for Children, Bristol, UK and †Consultant Anaesthetist, Royal United Hospital, Bath, UK
In 1988, when the Laryngeal Mask Airway-ClassicTM (Intavent Orthoﬁx, Maidenhead, UK), was introduced there were only two choices of airway management: tracheal tube or facemask. The supraglottic airway, as we now understand the term, did not exist. Yet, 20 years later, we are faced with an ever increasing choice of supraglottic airway devices (SAD). For many SADs, with the exception of the LMA-ClassicTM and LMA-ProsealTM (Intavent Orthoﬁx, Maidenhead, UK), there is a lack of high quality data of efﬁcacy. The best evidence requires a randomized controlled trial comparing a new device against an established alternative, properly powered to detect clinically relevant differences in clinically important outcomes. Such studies in children are very rare. Safety data is even harder to establish particularly for rare events such as aspiration. Therefore, most safety data comes from extended use rather than high quality evidence which inevitably biases against newer devices. For reason of these factors, claims of efﬁcacy and particularly safety must be interpreted cautiously. This narrative review aims to present the evidence surrounding the use of currently available pediatric SADs in routine anesthetic practice. Keywords: Laryngeal mask; proseal; airway; children; pediatric
In 1988, when Brain (1) introduced the Laryngeal Mask Airway-ClassicTM (cLMA, Intavent Orthoﬁx, Maidenhead, UK), there were only two choices of airway management: tracheal tube (TT) or facemask. The supraglottic airway, as we now understand the term, did not exist. Yet, 20 years later, we are faced with an ever increasing choice of supraglottic airway devices (SAD).
Correspondence to: Dr M. White, Department of Paediatric Anaesthesia, Bristol Royal Hospital for Children, Marlborough Street, Bristol BS2 8BJ, UK (email: email@example.com). Ó 2009 The Authors Journal compilation Ó 2009 Blackwell Publishing Ltd
A SAD can be pragmatically deﬁned as a device designed to maintain a clear airway, which sits outside of and creates a seal around the larynx. The term extraglottic may be more accurate but is not in common use. Most SADs are designed for use during routine anesthesia, but there are other roles such as airway rescue after failed intubation, use as a conduit to facilitate tracheal intubation and use by primary responders at cardiac arrest or other out-of-hospital emergencies. This review focuses on their primary role: elective anesthesia. SADs are intrinsically more invasive than use of a facemask for anesthesia, but less invasive than tracheal intubation. Accepting that
The fLMA was introduced in 1990. Engineered Medical Systems. Although children are not ‘small adults’ and we cannot extrapolate from adult data. IN) and LMA-ProsealTM (PLMA.10). In this review we divide SADs into ﬁrst and second generation devices. properly powered to detect clinically relevant differences in clinically important outcomes. Maidenhead. raising concerns over the ability to Aims and limitations This narrative review aims to present the evidence surrounding the use of currently available pediatric SADs in routine anesthetic practice: the cLMA. (iii) ability to ventilate through the device. particularly protection of the airway against regurgitation and pulmonary aspiration. Intavent Orthoﬁx. use of a facemask is impractical for many procedures. Complications commonly encountered are obstruction and laryngospasm. Wokingham. WHITE ET AL. In 2003. UK). 1). the ULMA made from polyvinyl chloride (PVC) was introduced (4). speciﬁcally designed for use in ENT and dental anesthesia (3). increased complication rates up to 47% are reported (7–9). Indianapolis. 55–65 . Ó 2009 The Authors Journal compilation Ó 2009 Blackwell Publishing Ltd. claims of efﬁcacy and particularly safety must be interpreted cautiously. In 1997. where adult evidence is relevant (or the only data available). the design patent for the cLMA (but not its epiglottic bars) expired and since then many other single-use devices have been manufactured. The cLMA has ﬁrst time insertion rates of 90%. We present the evidence for cLMAs and fLMAs in pediatric practice. Although the evidence base in children is smaller than in adults.8). 19 (Suppl. released in 2003 (5). As larger children and adolescents necessitate the use of adult sized devices. ﬂexible LMA (fLMA. Single-use devices (termed laryngeal masks (LM). we are unable to make speciﬁc recommendations concerning different manufacturers. (iv) safety. However. Given its lower invasiveness. UK). Classic and ﬂexible LMA. UK) and LMA-SupremeTM (SLMA. Maidenhead. UK). Some manufacturers have also produced reusable versions and economic and technical comparisons for some of the available devices are presented elsewhere (5). It is a re-usable device made of silicone and can be considered the benchmark against which all other SADs must be judged. second generation devices incorporate speciﬁc design features to improve safety by protecting against regurgitation and aspiration. Cobra Perilaryngeal Airway (CobraPLA.C. However. Intavent Orthoﬁx. For many SADs. most safety data comes from extended use rather than high quality evidence which inevitably biases against newer devices. First generation supraglottic airway devices The laryngeal mask airway (cLMA.12). the ﬁrst single-use LMA. the efﬁcacy and safety in pediatric practice has been reported in several large studies (7–9). (ii) surgical access. The cLMA was invented by Brain in 1983(2) and introduced into routine practice in 1998 (1). ULMA) and other laryngeal masks Historical context. fLMA. although a number of silicone devices are also available. Maidenhead. in small infants. First generation devices are simply ‘airway tubes’. The cLMA (Figure 1a) is widely used in routine anesthesia for children and has also greatly aided the management of children with difﬁcult airways (6). this is reported. Maidenhead. as there is minimal pediatric clinical data to support their efﬁcacy or safety compared with the cLMA. overall insertion rates of 99–100% and a low rate of serious complications (<11%) (7. Intavent Orthoﬁx. the ﬁrst of which was the Portex Soft Seal. with the exception of the cLMA and PLMA. the i-gelTM (Intersurgical. there is a lack of high quality data of efﬁcacy. Therefore. to distinguish them from the LMA) are generally made of PVC or plastic. the choice of airway therefore often lies between TT and SAD. Safety data is even harder to establish particularly for rare events such as aspiration. whereas. Intavent Orthoﬁx. For reason of these factors. The airway leak pressure in infants is also lower than in larger children (11.56 M. UK) are also discussed. Pediatric Anesthesia. Such studies in children are very rare. reasons not to use a SAD for all cases relate to concerns over (i) stability of the airway. LMA-UniqueTM (ULMA. The best evidence requires a randomized controlled trial comparing a new device against an established alternative. Epiglottic downfolding is commonly seen during ﬁbreoptic inspection of the larynx via the cLMA but its relation to airway obstruction is less clear (7. Both the i-gel and SLMA are currently only available in adult sizes but pediatric sizes are in development and expected to be released in 2009.
24) including a recent study of critical care nurses. have the largest evidence base for efﬁcacy and safety and are the benchmark by which other devices should be evaluated. Indianapolis.28). For adenotonsillectomy. Therefore routine use of cuff manometers is recommended (27. signiﬁcant cuff hyperinﬂation (median cuff pressures of 90 to >120 cm H2O)resulted (27). and in children with an upper respiratory tract infection they are associated with fewer complications than a TT (26). The fLMA is useful for head and neck surgery including ENT. Safety concerns focus on gas leakage around the cuff potentially leading to gastric distension and increased risk of regurgitation and pulmonary aspiration. Many anaesthetists choose the cLMA rather than a facemask for airway management for the practical reason of allowing their hands to be free for other tasks.14). Compared with the TT. positive pressure ventilation via a cLMA. the cLMA and fLMA have revolutionized pediatric anesthetic practice. dental and ophthalmic anesthesia. which showed no difference in successful ventilation using a cLMA or facemask (25). provide both effective and safe. The advent of quality single-use fLMAs (13) may change this practice. This may be because of concerns over transmission of infection with re-usable devices. the fLMA is reported as similar or better than the TT (15–17). Limitations include: higher complication rates in small infants (7–9). 1). The efﬁcacy of the fLMA (Figure 1b) has been evaluated in a number of large studies (13. However. yet airway management with a TT is still commonest practice (18). 55–65 . They are the most well established SADs in children. IN) Ó 2009 The Authors Journal compilation Ó 2009 Blackwell Publishing Ltd. Neuropraxia and ulceration can also occur.12).0.28). 19 (Suppl. Routine methods of cleaning laryngeal masks do not completely remove protein deposits (19–21). Cobra Perilaryngeal Airway The Cobra Perilaryngeal Airway (CobraPLA) (Engineered Medical Systems.P E D I A TR I C S U P R A G L O T T I C A I R W A Y D E V I C E S 57 (a) (b) Figure 1 (a) LMA size 1.5 and 1. In most cases they are a more practical choice than using a facemask. and commonly used methods of sterilization do not denature prions (22). In summary. but when used in a study of 640 children. cuff hyperinﬂation and poor seal if a pressure manometer is not used (27. Moylan evaluated the fLMA in 145 children undergoing 2500 radiotherapy procedures (14). Flynn evaluated single use and reusable fLMAs in 100 children undergoing dental procedures and found them to be equally efﬁcacious (13). (b) ﬂexible LMAs. and concerns around cuff leakage and potential gastric inﬂation during positive pressure ventilation (11. improved the airway seal (28). Pediatric Anesthesia. the actual evidence for the cLMA providing a better airway than a facemask during routine anesthesia is equivocal (23. the cLMA is less invasive and this has implications in children with upper respiratory tract infections in whom the cLMA is reported as having fewer airway complications than the TT (26). A subsequent study in 200 children reported that lowering cuff pressures to the recommended range (<60 cmH2O). Clinical end points are often used to guide cuff inﬂation and determine optimal positioning and seal.
19 (Suppl. observed gastric insufﬂation in 21% of children ventilated at pressures of 20 cmH2O or less (32). no randomized controlled trial has compared the PLMA with the CobraPLA. (a) (b) ﬁbreoptic inspection in contrast to with Polaner who reported epiglottic folding causing partial or complete obstruction of the larynx in 77% of infants (31). The evidence base. Pediatric sizes have been available in the world market since 2005 but only in the UK since 2007. mean oropharyngeal leak pressure (24–40 cm H2O) and ﬁbreoptic view of the larynx (86–92%) (37–39). (b) Cobra PLA size 3. effective airway management (99–100%). four of which are designated for pediatric use: size 0.0. Although. Several randomized controlled trials have compared the PLMA with the cLMA (11. and in adult sizes (3–5) there is an additional dorsal cuff but this is lacking in pediatric sizes (2. compared with the cLMA is very much smaller and concerns over safety have yet to be resolved. size 1. has good anatomical position (except size 1. size 2. To date. In summary.0 (31–60 kg).5 (16–30 kg). (Figure 2a. Pediatric Anesthesia. the cuff section is larger and more bowl-shaped. Passariello. The PLMA differs from the cLMA (Figure 3b) having an oesophageal drain tube and integral bite block.C.5. size 1. Therefore. 55–65 .b) is single use. the Cobra PLA. WHITE ET AL.5) and the neonatal size 1. ﬁrst generation SAD. Second generation pediatric devices Laryngeal Mask Airway – Proseal. currently the authors do not recommended the CobraPLA for routine use in children.5) and signiﬁcantly higher oropharyngeal leak pressures compared with the cLMA.0 (7. However. introduced in 2003.12.5 (2. but Szmuk (29) reported no difference. Szmuk also reported less gastric insufﬂation with the CobraPLA compared with the ULMA (29).5–15 kg). Both studies reported no laryngeal obstruction on Ó 2009 The Authors Journal compilation Ó 2009 Blackwell Publishing Ltd.5–7. and a proximal cuff which when inﬂated occupies the lower oropharynx. without offering any obvious advantage. This gives cause for concern particularly as an adult study by Cook was stopped early after two cases of aspiration were seen in low-risk elective adult patients (33).40–43). The PLMA (Figure 3a) is second generation SAD designed for controlled ventilation and increased airway protection. the Cobra PLA seems similarly efﬁcacious to the cLMA. 2. Figure 2 (a) Cobra PLA. 1). The CobraPLA has been compared with the ULMA by Szmuk (200 children) (29) and Gaitini (80 children) (30) and no differences were reported for time or ease of insertion. It is manufactured in eight sizes. The pediatric PLMA has been extensively studied and consistently performs well when evaluated for ease of insertion (ﬁrst time insertion 84–94%). like the ULMA or cLMA has no speciﬁc design features to prevent regurgitation or aspiration.58 M. other adult studies have reported favorable results (34–36).0 (Figure 3c). It comprises a widened distal end (head) with a somewhat ﬂexible tip. 1. These studies are summarized in Table 1 and show that the PLMA is easy to insert.5 kg). Gaitini (30) reported higher overall oropharyngeal leak pressures with the CobraPLA.
P E D I A TR I C S U P R A G L O T T I C A I R W A Y D E V I C E S 59 (a) (b) (c) (d) (e) Figure 3 (a) PLMA size 3 and size 1. Pediatric Anesthesia. (b) Size 1.5 PLMA and cLMA. (c) PLMA size 3.5 without dorsal cuff.0 with dorsal cuff and size 1. (e) Alternative insertion technique – PLMA railroaded over a bougie via oesophageal drain tube.5. Manufactures guidelines recommend the size 1.5 is used in children weighing 5–10 kg and Goldmann’s results (12) suggest that this size may be too large for very small infants. (d) PLMA mounted on the introducer tool. 55–65 . Fibreoptic examination of the airway during use showed narrowing caused by ‘bulging of supraglottic tissue’ thereby obstructing Ó 2009 The Authors Journal compilation Ó 2009 Blackwell Publishing Ltd. 1). 19 (Suppl.
5 n = 30 Better with PLMA (84% v 40%) No difference 23 vs 16 No difference No difference No difference (19 vs 18) 33 vs 26 Less blood staining of mask in PLMA group No difference No Difference No difference No difference No difference No difference but initial airway quality better with PLMA (P = 0. Insertion techniques. In this study the mean oropharyngeal leak pressure for PLMA was 29 ± 3 cmH2O and ﬁrst time insertion success rate 88%. Pediatric Anesthesia.0 n = 60 Lopez-Gill (40) Size 2.39.0 n = 51 Shimbori (41) Size 2. but the optimal insertion technique is unclear.12.5 n = 30 No difference but initial airway quality better with PLMA (P = 0. Table 1 Summary of randomized controlled trials comparing the PLMA with cLMA Laryngeal view on ﬁbreoptic bronchoscopy Better with PLMA PMLA vs cLMA Oropharyngeal leak pressure (cm H2O) 22 vs 18 neutral 37 vs 26 ﬂexion 15 vs 13 extension Ease of insertion Goldmann (43) Size 2. the operation and anesthesia times were shorter in the Ó 2009 The Authors Journal compilation Ó 2009 Blackwell Publishing Ltd. in routine clinical practice. 55–65 .0 is available and has been used in neonatal resuscitation and manikin studies (45. all of which are very simple to perform. gum elastic bougie (GEB) guided insertion techniques (Figure 3e) are reported as comparable with the introducer tool (48).01) No difference Mucosal trauma No difference Lardner (42) Size 2.C. Another use of the PLMA is for gastroscopy (54). WHITE ET AL. where epiglottic downfolding is reported without causing clinical airway obstruction (7.40–43). and better than a digital technique (49). such as depth of insertion. A size 1. New uses.46) but its efﬁcacy in routine elective anesthesia is unknown.53) and by the authors of this article.37. When compared with nasal cannulae. The manufacturers recommend using digital manipulation or the metal introducer tool (47) (Figure 3d). more studies are needed before the PLMA can be recommended for routine use during pediatric laparoscopic surgery.0 n = 240 Goldmann (11) Size 2. The PLMA is at least as easy to use as the LMA (11.001) Better with cLMA as obstruction seen in 5 vs 1 patient in PLMA vs cLMA groups respectively 18 33 13 27 36 18 vs vs vs vs vs vs 15 29 11 19 28 15 neutral ﬂexion extension neutral ﬂexion extension Less blood staining of mask in PLMA group Less blood staining of mask in PLMA group the view of the vocal cords. undergoing laparoscopy. The PLMA has been compared with the TT in sixty children.52). Despite this ﬁnding the airway was not compromised and was superior to the cLMA. Despite this favorable result. Although several studies (12.39) report high insertion success rates with the size 1. leak pressure and maximum minute ventilation to resting minute ventilation ratio (MMV ⁄ RMV) have also been veriﬁed in children (51). Suction catheter guided techniques are also reported as more successful and associated with less mouth trauma than digital techniques (50). This is similar to other studies of the cLMA. Clinical tests of malposition described for adults. Gel displacement tests (47. bilateral chest movement and square wave capnography.0 n = 30 Goldmann (12) Size 1. are also used to assess positioning in many studies (12.5. aged 6 months to 8 years.60 M.10). very much lower ﬁrst time (58%) and overall (75%) insertion success rates are reported in one study (44). The use of jaw thrust and ⁄ or partial cuff inﬂation have also given high success rates (39). 19 (Suppl. However. 1). and reported to have comparable ventilatory efﬁcacy (53).
1 ⁄ 71 (57) and 9 ⁄ 100 patients (58).12. There is some evidence the PLMA may be too large in very small infants (12.40–43). 55–65 . The i-gel has a noninﬂatable cuff made from a gel-like thermoplastic elastomer. This. The PLMA is a re-usable device and no single-use version exists. However. UK) (Figure 4a.62) remains to be seen. the limits of which are as low as the cLMA and as high as the PLMA.62) and PLMA have had reported problems (7. (a) (b) Other second generation devices currently only available in adult sizes i-gel airway. makes the PLMA the optimum pediatric SAD available for use in routine anesthesia. This aside. many hospitals still use reusable SADs for economic reasons and user preferences (56). Wokingham. There are no pediatric size i-gels at the time of writing. (b) i-gel.8. feature of the oesophageal drainage tube while it’s elliptoid shape offers greater stability. especially in infants under 10 kg where both the cLMA (7.b) is a relatively new single-use device. Pediatric Anesthesia. In summary. 19 (Suppl. Early adult reports show overall insertion rates of 97–100% but median seal pressures vary widely from 20 to 32 cm H2O (57–60). 1). Limitations. The stem is elliptical in cross-section to minimize axial rotation and provide greater stability. It retains the safety Figure 4 (a) i-gel. the i-gel’s offers the possibility of a genuine improvement on the PLMA. Few complications are noted and in particular the incidence of sore throat is very low. Whether such stability is retained in the pediatric sizes. There is one report of neuropraxia (61) associated with the i-gel and due to its bulky size this possibility should be kept under review. combined with the added safety feature of the oesophageal drain tube. The PLMA is easy to insert whichever technique is chosen and has yet to be outperformed by any other SAD (11. It contains both airway and drainage tubes. the evidence base for the PLMA is smaller than the cLMA as it is a newer device.P E D I A TR I C S U P R A G L O T T I C A I R W A Y D E V I C E S 61 PLMA group and oxygen saturations were higher (100% vs 94%) (36). and an integral bite block.44).12. but these are under development and anticipated to be released in 2009. Single-use devices are encouraged to reduce the possibility of transmission of prions and other infectious material from one patient to another (55). Ó 2009 The Authors Journal compilation Ó 2009 Blackwell Publishing Ltd.44. There was no difference in the ease of performing the endoscopy procedure. The i-gelTM (Intersurgical. The manufacturers claim the cuff is ‘anatomically shaped’ and the airway seal improves as the device warms to body temperature.
Other currently available adult SADs include.64) but it is too early to determine the role of this SAD in adults or children. Maidenhead. Gmblt. the ability to achieve high seal pressures and separation of the gastrointestinal and respiratory tracts (PLMA). oropharyngeal leak pressure (28 cm H2O) and gastric access (63).C. Pediatric Anesthesia.62 M. the SLMA performed equally well with respect to insertion success (97%). Figure 6 Laryngeal Tube Sonda and Laryngeal Tube Sonda Mark II. Therefore. ellipsoid anatomically shaped stem which facilitates easy insertion. Namely. together with extreme ease of insertion without the need for introducer tools or inserting ﬁngers in the mouth (ILMA). WHITE ET AL. When compared with the PLMA. (a) Figure 5 LMA – Supreme. the SLMA has both an airway and oesophageal drainage tube together with an integral bite block molded into a ﬁrm. UK) (Figure 5) is another new single-use device currently unavailable in pediatric sizes although. 19 (Suppl. The stem is much stiffer than the PLMA but is intended to accommodate movements of the head and neck unlike the rigid metal stem of the ILMA. Sulz. 55–65 . The SLMA was designed to combine the desirable features of the PLMA and the intubating laryngeal mask airway (ILMA). these are anticipated in 2009. (b) SLIPA. Germany) (Figure 6). The LMA-SupremeTM (SLMA. like the i-gel. Medizintechnik. Intavent Orthoﬁx. (b) Figure 7 (a) SLIPA. Ó 2009 The Authors Journal compilation Ó 2009 Blackwell Publishing Ltd. The literature in adults is growing (4. Laryngeal Mask Airway – Supreme.63. Other devices New SADs continue to be developed at such a rate that keeping up-to-date in this subject is difﬁcult. 1). The inﬂatable cuff design of the PLMA is retained but has been modiﬁed and enlarged to enhance the anatomical ﬁt in the pharynx. the Laryngeal Tube and Laryngeal Tube Sonda II (VBM.
several of which are now available in pediatric sizes with more expected soon (see Table 2). 5 NHS Purchasing and Supply Agency. Conclusion Since the early 1990s.5–7. Br J Anaesth 1998. 80: 677–679. early clinical studies and experimental work from which the Laryngeal Mask evolved. A modiﬁed Intavent laryngeal mask for ENT and dental anaesthesia. Anaesthesia 1990.5 subgroup) Size 1. 45: 892–893. over existing ones. ﬁrst and second generation reusable SADs respectively. Centre for Evidenced Based Publishing Buyers’ Guide: Laryngeal Masks.pasa. Crawford D. Cook has received speaker fees from Intavent Orthoﬁx and the LMA Company. Wilkes A. Conﬂicts of interest T.5 kg 1. and evidence supporting efﬁcacy and safety is often absent or inadequate. Eur J Anaesthesiol Suppl 1991. For references see text. Hudson. Ó 2009 The Authors Journal compilation Ó 2009 Blackwell Publishing Ltd.5 poor anatomical ‘ﬁt’ and possible difﬁcult insertion i-gel SLMA 2nd 2nd One episode of neuropraxia in an adult 2nd generation devices incorporate design features to reduce regurgitation risk. 19 (Suppl. 1). Their role and that of other SADs in routine anesthetic practice is not established. Br J Anaesth 1983. The PLMA has yet to be outperformed References 1 Brain AI. Berlet J.0 : <5 kg 1.5 : 5–10 kg 2.5 : 20–30 kg Expected 2009 Expected 2009 1st or 2nd generation 1st Pediatric OLP pressure (cm H2O) 11–30 depending on size of device Overall insertion success rate 99–100% Areas of potential concern Size 1.65–70) regarding these devices and the authors do not recommend any of them for use in children or adolescents. considerable high quality research is required to sort the ‘wheat from the chaff’. www. Many new SADs. The laryngeal mask–a new concept in airway management.NHSprocurement/CEP/CEPproducts/CEP+catalogue (accessed April 19 2009).P E D I A TR I C S U P R A G L O T T I C A I R W A Y D E V I C E S 63 Table 2 Summary of supraglottic airway devices Pediatric sizes. July 2008. and the Streamlined Liner of the Pharyngeal Airway (SLIPA.uk/PASA Web. New devices will continue to reach the market place and while some offer the possibility of a genuine advance. The cLMA has the largest evidence base for safety and efﬁcacy and is therefore the benchmark by which other devices are compared. Oropharyngeal leak pressure. while other alternative SADs exist which have been more extensively evaluated. 4 Verghese C. Pediatric Anesthesia. appear to offer little or no beneﬁt for clinician or patient. with the exception of the PLMA.0 : 10–20 kg 2.5–15 kg 1.5 : 20–30 kg 0.5 : 5–10 kg 2. by any other SAD making it the premier SAD in children and the benchmark by which newer second generation devices should now be compared.nhs. Kapila A et al. 55: 801–805. White and P. RCI) (Figure 7a. 4: 5–17. eds. 55–65 . 2 Brain AI. recommended weight range cLMA 1.0 : 7. 3 Alexander CA. There is currently insufﬁcient evidence (and in some cases negative evidence) (61. Clinical assessment of the single use laryngeal mask airway–the LMA-unique.b) which has a unique hollow boot-shaped chamber providing storage (50 ml) for regurgitated liquids and particulate matter.5 : 2. CEP 08010.5 poor anatomical ‘ﬁt’ Cobra PLA 1st 15–18 100% Gastric inﬂation and in adults cases of aspiration PLMA 2nd 13–37 99–100% (one report of 74% in size 1. The development of the Laryngeal Mask–a brief history of the invention.5 : 16–30 kg 2. pediatric anesthetic practice has been revolutionized by increasing use of the cLMA and fLMA. OLP. Stoddart have declared no conﬂicts of interest.0 : 31–60 kg 1.0 : 10–20 kg 2.0 : <5 kg 1. The last 5 years has seen the development of numerous SADs. M.
16 Williams PJ. Bingham RM. Anesth Analg 2006. Presence of protein deposits on ‘cleaned’ re-usable anaesthetic equipment. Kinirons B. A cohort evaluation of the pediatric proseal laryngeal mask airway in 100 children. Pediatr Anesth 2006. crossover investigation with the Classic laryngeal mask airway. The laryngeal mask airway in children. 26 Tait AR. Br J Anaesth 2007. 60: 791–796. 92: 777–778. Carmi N. 8 Lopez-Gil M. 56: 1069–1072. Ewen A et al. 63: 738– 744. 39: 56–63. 19: 171–172. Gibbison B. Mitchell V et al. A study comparing routinely cleaned masks with three alternative cleaning methods. 47: 315–318. 10 Dubreuil M. 70: 30–33. Safety and efﬁcacy of the laryngeal mask airway. 22 Taylor DM.Proseal and the LMA-Classic in ventilated children receiving neuromuscular blockade. 55–65 . 95: 827–830. 45: 760–763. Karunaratne WU et al. Robb PJ et al. Alvarez M. Yanovski B. 100: 1605–1610. Can J Anaesth 1993. Clifton S et al. An evaluation of the Cobra Perilaryngeal Airway: study halted after two cases of pulmonary aspiration. randomized comparison of cobra perilaryngeal airway and laryngeal mask airway unique in pediatric patients. 16: 297–301. 71: 172. Comparison of armoured laryngeal mask airway with endotracheal tube for adenotonsillectomy. Pediatr Pulmonol 2005. 1). Ghelber O. Comparison of the reinforced laryngeal mask airway and tracheal intubation for adenotonsillectomy. Laryngeal mask airway and tracheal tube cuff pressures in children: are clinical endpoints valuable for guiding inﬂation? Anaesthesia 2008. Hersch P et al. Anaesthesia 2001.C. Licina A. Comparison of the CobraPLA (Cobra Perilaryngeal Airway) and the Laryngeal Mask Airway Unique in children under pressure controlled ventilation. Br J Anaesth 2005. Anesth Analg 2006. 18: 313–319. Kelly F. Chambers NA. Br J Anaesth 2004. Morley-Forster PK. Pandit UA. 93: 528–531. Insertion characteristics. Video assessment of supraglottic airway orientation through the perilaryngeal airway in pediatric patients. 6 Walker RW. Plaud B et al. 62: 790–795. Luce MA. Anesth Analg 2005. Pediatr Anesth 2008. Lopez-Gil M. Anesth Analg 2008. Brimacombe J. Loach VJ. Gaitini L. Goldmann K. Pediatric Anesthesia. Anesth Analg 2006. Paediatr Anaesth 2000. ProSeal laryngeal mask airway in 120 pediatric surgical patients: a prospective evaluation of characteristics and performance. Akca O. crossover investigation with the standard laryngeal mask airway in paediatric patients. Lowe JM. 102: 631–636. Bailey PM. Pediatr Anesth 2007. Brimacombe J. Comparison of laryngeal mask airway (LMA). Airway management for tonsillectomy: a national survey of UK practice. The CobraPLA in 110 anaesthetized and paralysed patients: what size to choose? Br J Anaesth 2004. 97: 1189–1191. Agro F. Cox RG. Voepel-Lewis T et al. 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