Anaesth Intensive Care 2004; 32: 804-808

Equipment
Positive Pressure Versus Pressure Support Ventilation at
Different Levels of PEEP Using the ProSeal™ Laryngeal
Mask Airway
A. VON GOEDECKE*, J. BRIMACOMBE†, C. KELLER‡, C. HOERMANN‡, A. LOECKINGER*,
J. RIEDER*, A. KLEINSASSER*
Department of Anesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria, and Cairns Base
Hospital, The Esplanade, Cairns, Queensland

SUMMARY
We compared positive pressure ventilation with pressure support ventilation at different levels of positive end
expiratory pressure (PEEP) using the ProSeal laryngeal mask airway (PLMA). Forty-two anaesthetized adults (ASA
1-2, aged 19 to 63 years) underwent positive pressure ventilation and then pressure support ventilation each with
PEEP set at 0, 5 and 10 cmH2O in random order. Pressure support ventilation was with the inspired tidal volume
(VTInsp) set at 7 ml/kg and the respiratory rate adjusted to maintain the end-tidal CO2 (ETCO2) at 40 mmHg.
Pressure support ventilation was with pressure support set at 5 cmH2O above PEEP and initiated when inspiration
produced a 2 cmH2O reduction in airway pressure. Tidal volumes were similar during positive pressure and pressure
support ventilation with PEEP, but were higher for the former without PEEP. Respiratory rate and peak inspiratory
flow rate were higher during pressure support than positive pressure ventilation (all P<0.001). Peak airway pressure
(Ppaw), mean airway pressure (Mpaw), peak expiratory flow rate, and expired airway resistance were lower during
pressure support than positive pressure ventilation (all P<0.001). With PEEP set at 10 cmH2O, ETCO2 was lower
for pressure support than positive pressure ventilation. During positive pressure ventilation, there was an increase in
Ppaw, Mpaw and dynamic compliance (Cdyn) with increasing levels of PEEP (all P<0.01). During pressure support
ventilation, there was an increase in inspired and expired tidal volume, Ppaw, peak inspiratory and expiratory flow
rates and Cdyn, and a reduction in ETCO2, work of breathing, and expired airway resistance with increasing levels
of PEEP (all P<0.01). There were no differences in SpO2, non-invasive mean arterial pressure, heart rate or leak
fraction. We conclude that pressure support ventilation provides equally effective gas exchange as positive pressure
ventilation during PLMA anaesthesia with or without PEEP at the tested settings. During pressure support, PEEP
increases ventilation and reduces work on breathing without increasing leak fraction.
Key Words: ANAESTHESIA: laryngeal mask airway; ventilation, PEEP, pressure support ventilation

Positive end-expiratory pressure (PEEP) is fre-
quently used in tracheally intubated patients to
increase oxygenation, but is rarely used with the
laryngeal mask airway (LMA) because the low
*M.D., Consultant Anesthetist, Department of Anesthesia and Intensive
Care Medicine, Leopold-Franzens University, Innsbruck, Austria.
†M.B., Ch.B., F.R.C.A., M.D., Professor, James Cook University,
Department of Anaesthesia and Intensive Care, Cairns Base Hospital,
Cairns.
‡M.D., Associate Professor, Department of Anesthesia and Intensive Care
Medicine, Leopold-Franzens University, Innsbruck, Austria.
Address for reprints: Dr J. Brimacombe, Dept of Anaesthesia and Intensive
Care, Cairns Base Hospital, The Esplanade, Cairns, Qld 4870.
Accepted for publication on July 22, 2004.
pressure seal predisposes to oropharyngeal and
oesophageal air leaks1. The ProSeal™ LMA (PLMA)
(LMA ProSeal™. San Diego, U.S.A.) is a new laryn-
geal mask device with a modified cuff to improve the
seal and a drain tube that prevents gastric insufflation
when correctly positioned2-4. Pressure support ventila-
tion (PSV—partial support of spontaneous respira-
tion by applying a predefined constant pressure
during the inspiratory phase of each spontaneous
breath) improves gas exchange during spontaneous
breathing with the LMA5, but there is only one pre-
vious study, which was published in abstract form,
comparing it with positive pressure ventilation
(PPV)6. In principle, the combination of PEEP and
Anaesthesia and Intensive Care, Vol. 32, No. 6, December 2004
 PRESSURE SUPPORT WITH THE PROSEAL LMA
the PLMA might be particularly beneficial for venti-
lated patients, as PEEP improves gas exchange5, and
the LMA does not increase pulmonary airway resis-
tance7 or impede ciliary motility8. In the following
study, we compare PPV with PSV at different levels
of PEEP with the PLMA.
METHODS
Forty-two adults (ASA 1-2, aged 19 to 63y) under-
going elective peripheral musculoskeletal surgery
were studied. Ethics committee approval was
obtained from the Leopold-Franzens University and
written informed consent was obtained from the
patients. The study was conducted in Austria. Ex-
clusion criteria were a known or predicted diffi-
cult airway, mouth-opening <2.5 cm, a body mass
index 35 kg/m2, or if they were at risk of aspira-
tion (fasted <6h; gastro-oesophageal reflux >once
weekly).
Premedication was with oral midazolam 7.5 mg one
hour preoperatively. Anaesthesia was in the supine
position with the patient’s head on a standard pillow
5 cm in height. A standard anaesthesia protocol was
followed and routine monitoring applied. Fentanyl
2 to 3 µg/kg was administered and patients were
preoxygenated for three minutes. Anaesthesia was
induced with propofol 2.5 to 3.5 µg/kg given over
30 seconds and the PLMA™ was inserted when there
was no response to jaw thrust9. Additional boluses of
propofol 0.5 mg/kg were given as required until an
adequate level of anaesthesia was achieved for place-
ment. A single experienced PLMA™ user (>400
uses) inserted/fixed the PLMA™ (size 4 females, size
5 males) according to the manufacturer’s instruc-
tions10. Once an effective airway was obtained, the
intra-cuff pressure was set and held constant at 60 cm
H 2O using a digital manometer (Mallinckrodt
Medical, Athlone, Ireland). The oropharyngeal leak
pressure was determined by closing the expiratory
valve of the anaesthesia breathing system at a fixed
gas flow of 3 l/min and noting the airway pressure
(maximum allowed, 40 cmH2O) at which equilibrium
was reached11. Epigastric auscultation was performed
during oropharyngeal leak pressure testing to detect
any gastric insufflation12. The anatomic position of
the airway tube was determined by passing a fibre-
optic scope to a position just proximal to the end of
the airway tube and scoring the view13. The position of
the drain tube was determined by placing a clear
lubricant in the proximal 1 cm of the drain tube and
noting whether bubbling occurred during ventilation3.
The patency of the drain tube was determined by
passing a catheter to its distal end14. If malposition
was suspected, the PLMA was reinserted.
Anaesthesia and Intensive Care, Vol. 32, No. 6, December 2004
805
Respiratory variables were measured and analysed
using a pulmonary monitor (CP-100, BiCore Moni-
toring System, Irvine, U.S.A.) attached to a variable
orifice pneumotachograph (Var flex, Allied Health
Products, Riverside, U.S.A.) and an oesophageal bal-
loon catheter inserted through the drain tube (Smart
Cath, Allied Health Products, Riverside, U.S.A.)15-17 .
The oesophageal balloon catheter was 3 mm in
diameter, 70 cm long and constructed from medical
grade polyurethane. The inflated balloon was 0.9 cm
in diameter and 10 cm long. The frequency response
was 30 Hz. The oesophageal balloon catheter was
connected directly to the catheter port on the BiCore
monitoring system. The BiCore monitoring system
automatically performs a vacuum leak test and
fills the oesophageal balloon with 0.8 ml air. The
pneumotachograph was connected directly to the
proximal end of the airway tube. Airway pressure
was measured at the pneumotachograph. The CO2
sampling port was sited above the flow transducer.
The position of the oesophageal balloon catheter was
checked and adjusted where necessary by observation
of the cardiac artefact on the oesophageal waveform,
as recommended by the manufacturer. The anaesthe-
sia machine pop-off valve was set at 40 cmH2O. The
flow transducer was calibrated for the anaesthesia gas
mixture.
The patient was connected to an Evita 4 venti-
lator (Draeger Medizintechnik GmbH, Luebeck,
Germany). Positive pressure ventilation with a con-
stant square wave inspiratory flow profile was started.
The tidal volume was set at 7 ml/kg and the respira-
tory rate adjusted to maintain the end tidal CO2
(ETCO2) at 40 mmHg. The inspiratory:expiratory
ratio was 1:1 and was held constant. Anaesthesia
maintenance was with sevoflurane 1.5% and oxygen
30% in N2O. Intraoperative analgesia was with intra-
venous fentanyl. The cardiorespiratory variables were
recorded for 10 minutes when the ETCO2 was stable.
This was repeated at three different levels of PEEP
(0, 5 and 10 cmH2O) in random order (allocated by
opening an opaque sealed envelope). The lungs were
manually inflated until spontaneous ventilation re-
sumed. Patients underwent pressure support ventila-
tion (PSV). PSV comprised pressure support (PS) set
at 5 cmH2O above PEEP. PS was initiated when in-
spiration produced a 2 cmH2O reduction in airway
pressure. No minimal respiratory rate or apnoea
backup was set on the ventilator.
Each ventilatory mode/PEEP level was maintained
for 10 minutes. The following data were recorded
every minute for the last five minutes of each ventila-
tory mode/PEEP level and the average reading taken:
ETCO2, oxygen saturation (SpO2), non-invasive
806 A. VON GOEDECKE, J. BRIMACOMBE ET AL
mean arterial pressure, inspired (VTInsp) and
expired tidal volume (VTExp), leak fraction, respira-
tory rate, peak airway pressure (Ppaw), mean airway
pressure (Mpaw), peak inspiratory flow rate, peak
expiratory flow rate, work of breathing, dynamic com-
pliance (Cdyn), delta oesophageal pressure, expired
airway resistance (RAWe) and airway occlusion pres-
sure. Any ingestion or expulsion of air via the drain
tube was detected by observing movement of a col-
umn of lubricant placed in the drain tube before and
after oesophageal balloon catheter insertion.
Sample size was selected for a type I error of 0.05
and a power of 0.9 and was based on a pilot study of
10 patients with a measured difference in the expired
tidal volume (VTExp) of 15% between the pressure
support ventilation groups with 0 and 10 cmH2O
PEEP level. The distribution of data was determined
using Kolmogorov-Smirnov analysis 18 . Statistical
analysis was with one-way analysis of variance with
post hoc Bonferroni test. Unless otherwise stated,
data are presented as mean (SD). Significance was
taken as P<0.05.
RESULTS
Demographic, surgical and anaesthetic characteris-
tics are presented in Table 1. The PLMA was success-
fully inserted at the first attempt and was correctly
positioned in all patients. Gastric insufflation was not
detected during oropharyngeal leak pressure testing.
Oesophageal balloon catheter insertion was success-
ful at the first attempt in all patients. Haemodynamic
and respiratory characteristics are presented in Table
2. VTInsp and VTExp were similar during PSV and
PPV with PEEP, but were higher for PPV without
PEEP. Respiratory rate and peak inspiratory flow rate
were higher during PSV than PPV with or without
PEEP (all P<0.001). Ppaw, Mpaw, peak expiratory
flow rate and expired airway resistance were lower
during PSV than PPV with or without PEEP (all
P<0.001). With PEEP set at 10 cmH2O, ETCO2 was
lower for PSV than PPV. During PPV, there was an
increase in Ppaw, Mpaw and Cdyn with increasing
levels of PEEP (all P<0.01). During PSV, there was
an increase in VTInsp, VTExp, Ppaw, peak inspira-
tory flow rate, peak expiratory flow rate, Cdyn and a
reduction in ETCO2, work of breathing and expired
airway resistance with increasing levels of PEEP (all
P<0.01). There were no differences in SpO2, mean
arterial pressure, heart rate or leak fraction.
DISCUSSION
Gas exchange was similar for PSV and PPV when
PEEP was 5 cmH2O, but ETCO2 was lower for PSV
than PPV when PEEP was 10 cmH2O. This latter
TABLE 1
Demographic, surgical and anaesthetic characteristics. Data are
mean (SD) or numbers
N 42
Age; y 37 (13)
Height; cm 174 (11)
Weight; kg 74 (14)
Male: Female 29:13
ASA (1/2); n 19/23
Anaesthesia Drugs
—Propofol induction; mg.kg–1 3.1 (0.6)
—Fentanyl induction; µg.kg–1 2.9 (0.9)
—Fentanyl maintenance; mg.kg–1 0.5 (0.6)
—Sevoflurane maintenance; end-tidal conc % 1.5 (0.1)
Total anaesthesia time; min 105 (24)
Oropharyngeal leak pressure; cmH2O 30 (7)
Fibreoptic view airway tube; 4/3/2/1 10/16/14/2
finding was due to a higher respiratory rate and com-
parable tidal volume whereas with PEEP 5 cmH2O,
respiratory rate was higher, but tidal volume slightly
lower. Capdevila et al6, in a preliminary study, also
reported that gas exchange was similar for PSV and
PPV, but used the Classic LMA and tidal volumes of
8 ml/kg. PSV provides better gas exchange than spon-
taneous breathing in anaesthetized patients managed
with the tracheal tube19 or Classic LMA5.
Airway pressures were lower for PSV than PPV at
all levels of PEEP. This was due to lower airway resis-
tance possibly as a result of bronchodilation at the
start of each spontaneous breath. Capdevila et al6 also
reported lower peak pressures with PSV and found
that these were associated with a lower leak fraction.
However, we found that leak fraction was similar for
PSV and PPV. This is because peak airway pressures
were still much lower than oropharyngeal leak pres-
sure as we used the PLMA, whereas Capdevila et al
used the Classic LMA, which forms a less effective
seal2-4.
PEEP increased tidal volume, but reduced ETCO2
and work of breathing in patients undergoing PSV
without an increase in leak fraction. PEEP should be
safer to administer with the PLMA than the Classic
LMA, as it forms a better seal, and any oesophageal
leaks should be vented from the drain tube provided
it is correctly positioned. Iizuka and Ishii1, in a pre-
liminary study using the Classic LMA for pressure
controlled ventilation at 20 cmH2O, found that there
were no air leaks when PEEP 7 cmH2O, but air
leaks occurred in 4% of patients when PEEP was
10 cmH2O. CPAP reduces work of breathing with the
Classic LMA during spontaneous breathing20.
SpO2 was not increased by PEEP for PSV or PPV.
This may be related to the healthy state of the
patients lungs and/or because the SpO2 was already
Anaesthesia and Intensive Care, Vol. 32, No. 6, December 2004
 PRESSURE SUPPORT WITH THE PROSEAL LMA 807

TABLE 2
Haemodynamic and respiratory characteristics during positive pressure and pressure support ventilation at PEEP 0, 5 and 10 cmH2O. Data are
mean (SD) or numbers
Positive pressure ventilation Pressure support ventilation
PEEP level 0 5 10 0 5 10
Heart rate, min–1 56 (9) 56±8 56±8 59±9 58±9 59±9
Mean blood pressure, mmHg 82 (12) 84±11 84±12 89±14 86±15 87±15
Oxygen saturation, % 97.0 (1.3) 97.0±1.3 96.9±1.3 96.5±1.4 96.6±1.3 96.9±1.2
Respiratory rate, min–1 12 (1) 12±1 12±1 17±4 á 17±4‡ 16±4‡
Inspiratory tidal volume, ml 556 (99) 555±95 540±85 477±170‡ 516±171* 550±150*
Expired tidal volume, ml 553 (92) 553±91 538±76 474±165‡ 511±167* 546±144*
Leak fraction, % 0.5 (0.4) 0.4±0.4 0.4±0.4 0.7±0.7 0.9±0.8 0.8±0.9
End tidal CO2, mmHg 39 (4) 39±4 41±5 38±6 37±6 35±6 †‡
Peak airway pressure, cmH2O 12 (2.9) 16±2.8* 20±2.2* 5±0.7‡ 10±1*‡ 15±0.6*‡
Mean airway pressure, cmH2O 6 (1.5) 10±1.5* 15±1.4* 2±0.6‡ 7±0.5*‡ 12±0.5*‡
Peak inspiratory flow rate, l.s–1 0.48 (0.05) 0.48±0.06 0.51±0.08 0.73±0.19‡ 0.81±0.21*‡ 0.88±0.22*‡
Peak expiratory flow rate, l.s–1 0.85 (0.21) 0.83±0.23 0.74±0.26 0.49±0.12‡ 0.54±0.12*‡ 0.56±0.13*‡
Work of breathing, J.l–1 0.33±0.25 0.27±0.21* 0.22±0.17*
Dynamic compliance, ml.cmH2O–1 101 (43) 110±42* 122±42* 96±45 109±59* 118±47*
Delta oesophageal pressure, cmH2O 6.8 (2.2) 6.8±2.7 6.7±2.4 7.4±3.3 6.9±3.0 6.6±2.5
Expired airway resistance, cmH2O s–1.l–1 7.9 (5.9) 8.5±5.7 8.8±8.7 5.9±4.0á 4.5±3.2*‡ 4.1±2.5†‡
Airway occlusion pressure, cmH2O 1.4±1.1 1.4±1.4 1.4±1.4
Intragroup comparison: †P<0.01; *P<0.001. Intergroup comparison: ‡P<0.001.

close to maximum. Unfortunately, we did not
measure PaO2. We consider that the application of
PEEP may result in an improvement in oxygenation
in some patients, depending on the type and extent of
their respiratory disease. We speculate that PEEP
may be less effective at improving oxygenation with
the LMA than with the tracheal tube, because there
is less airway closure with the LMA7,21, and therefore
probably a smaller reduction in functional residual
capacity. CPAP improves oxygenation with the
Classic LMA during spontaneous breathing22.
We detected no difference in cardiovascular effects
between PSV and PPV. This is not surprising since
the average intrathoracic pressure changes were only
2 to 3 cmH2O higher for PPV.
The application of PEEP using the PLMA com-
bines the well-established benefits of PEEP (in terms
of gas exchange) with the reasonably well-established
benefits of not entering the larynx (in terms of non-
interference with the mucociliary tree8, minimal in-
creases in pulmonary airway resistance7, and reduced
airway reflex activation23). There is some evidence for
fewer postoperative adverse airway events with the
LMA than with the endotracheal tube in patients
with some forms of respiratory disease24-26.
We conclude that PSV provides equally effective
gas exchange to PPV during PLMA anaesthesia in
non-paralysed patients with or without PEEP at the
tested settings. During PSV, PEEP increases ven-
Anaesthesia and Intensive Care, Vol. 32, No. 6, December 2004
tilation and reduces work of breathing without
increasing leak fraction.
Financial Disclosure: This study was supported
solely by departmental resources.
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