Laryngeal Mask Airway SupremeTM Research Articles

A randomized controlled study to compare oropharyngeal leak pressure between I-gel™ and laryngeal mask airway supreme™ in children in lateral position under general anesthesia

BackgroundSupraglottic airway devices (SADs) are the mainstay for airway management in pediatric ambulatory surgeries and may often be a suitable alternative to endotracheal intubation due to their favorable profile. Optimal oropharyngeal leak pressure of SAD is essential for adequate ventilation and prevention of aspiration. Occasionally, lateral position is required for administration of regional block or for the surgery itself.We aim to compare the oropharyngeal leak pressure of igel™ and LMA Supreme™ in children in lateral position.A prospective, randomized study was performed on eighty children of either sex, weighing 5–10 kg, belonging to ASA grade I and II undergoing elective surgery requiring lateral position. The primary objective was comparison of Oropharyngeal leak pressure of both devices in lateral position. Secondary objectives included assessment of insertion success rate, number of insertion attempts and manipulations, time and ease of insertion; and comparison of fiberoptic view of the larynx, fractional volume loss, and displacement with respect to both devices in supine and lateral position.ResultsOropharyngeal leak pressure of i-gel™ was higher than that of LMA Supreme™ in both supine (25.4 ± 1.4 cm H2O Vs 22.9 ± 1.5 cm H2O) and lateral position (23.9 ± 1.6 vs 21.5 ± 1.5 cm H2O) and was statistically significant (p < 0.001). The success rate of insertion of i-gel™ and LMA Supreme™ was similar (95% and 97.5% respectively). The ease of insertion for both devices was statistically similar (p = 0.593). The mean time for insertion was longer for i-gel™ (15.4 ± 1.72 s vs 12.4 ± 1.73 s) as compared to LMA Supreme™ (p < 0.001). Ventilatory parameters for both devices decreased in the lateral position, which was statistically significant. The fractional volume loss after change of position was 0.123 vs 0.478 for i-gel™ and LMA Supreme™ respectively. In both groups, fiberoptic views worsened with a change of position.ConclusionsOropharyngeal leak pressure of both devices reduced in lateral position as compared to supine position. I-gel™ yielded higher leak pressures in supine as well as in lateral position as compared to LMA Supreme™.ImplicationsThe above findings offer valuable insight for decision-making in pediatric daycare surgeries requiring lateral position where GA is warranted.Trial registrationCTRI NUMBER (CTRI/2021/01/030442)—the trial was registered with the Clinical Trial Registry of India on 13 January 2021.

Clinical Performance Comparison of LMA Protector™ Cuff Pilot™ and LMA Supreme™ When Used in Anesthetized, Non-paralyzed Patients.

IntroductionThe advancement of supraglottic airways (SGAs) has eased airway management, especially for anesthetists. There were functional improvements implemented to the newer SGA. We aim to assess the clinical performance of laryngeal mask airway (LMA) Protector™ Cuff Pilot™ (Teleflex Inc., Wayne, Pennsylvania, USA) against LMA Supreme™ (Teleflex Inc., Wayne, Pennsylvania, USA), in terms of oropharyngeal leak pressure (OLP), successful insertion attempts, mean insertion time, ease of gastric tube insertion, laryngeal view, and incidence of sore throat among anesthetized, non-paralyzed patients undergoing general anesthesia.MethodsIn this prospective single-blinded study, 60 patients were randomized to use either LMA Protector™ Cuff Pilot™ or LMA Supreme™. Both groups received standard monitoring and induction regimes. Post-insertion, a bronchoscope was used to verify its position. A gastric tube was inserted and OLP was measured. Patients were assessed during the post-operative period for sore throats.ResultsLMA Protector™ Cuff Pilot™ was comparable to LMA Supreme™ in terms of mean OLP (30.72±8.60 vs 27.23±8.09 cmH2O, P = 0.114), first successful attempt (P = 0.312), mean insertion time (27.72±9.45 vs 24.37±6.46 seconds, P = 0.116), and grade 1 laryngeal view (51.7% vs 36.7%, P = 0.244). At first attempt, LMA Protector™ Cuff Pilot™ had a lower success rate of gastric tube insertion than LMA Supreme™ (55.17% vs 96.67%, P <0.001). The incidence of the blood-stained device and sore throat post-operatively were comparable between the two groups.ConclusionLMA Protector™ Cuff Pilot™ was comparable to LMA Supreme™ in terms of overall clinical performance, except for the first successful gastric tube insertion. Improvements should be made to the gastric channel for easier gastric tube insertion in the LMA Protector™ Cuff Pilot™.

Pharyngolaryngeal Morbidity With the Laryngeal Mask Airway SupremeTM at Different Fiberoptic Bronchoscopy Grades: An Observational Study.

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.

Safety and efficacy of LMA Supreme™ vs. LMA ProSeal™ for ambulatory surgeries in adult patients

Background &amp; objectives: The laryngeal mask airway Supreme™ (LMA-S) is a new, single-use, supraglottic device that combines the functionality of the ProSeal™ and Fastrach™ airways. Till now, there have been conflicting results regarding the oropharyngeal leak pressure (OLP) of the LMA Supreme™ vs. the LMA ProSeal™, which is the major determinant of effective ventilation and airway protection during LMA use. We compared the safety and efficacy of the LMA ProSeal™ vs. the LMA Supreme™ in ambulatory surgeries.&#x0D; Methodology: In this prospective, comparative trial, eighty adult patients undergoing elective surgery, were randomly allocated to one of the two groups: Group LMA–P (LMA ProSeal™ group) and Group LMA–S (LMA Supreme™ group) of 40 patients each. OLP, insertion times, number of insertion attempts, ease of insertion and pharyngolaryngeal morbidity were assessed. Statistical analysis was performed using SPSS version 21.0 software using Student’s t-test and Chi-square test. P &lt; 0.05 was considered to be statistically significant.&#x0D; Results: Oropharyngeal leak pressure in Group LMA–P (26.65 ± 1.59 cmH2O) was comparable to Group LMA–S (26.08 ± 1.67 cmH2O) and both provided adequate seal and effective ventilation. The mean effective airway time was significantly less in Group LMA–S as compared to Group LMA–P (14.80 ± 1.24 sec and 17.80 ± 1.47 sec) respectively. Mean number of successful insertion attempts, hemodynamic response and pharyngolaryngeal morbidity were comparable in both the groups.&#x0D; Conclusion: Both LMA Supreme™ and LMA ProSeal™ are equally efficacious and safe for maintaining airway and ventilation in paralyzed patients. However, LMA Supreme™ is easier to insert with shorter effective airway time than LMA ProSeal™.&#x0D; Abbreviations: SAD - Supraglottic airway device; ETI - Endotracheal intubation; LMA - Laryngeal mask airways; PPV - Positive pressure ventilation; OLP - oropharyngeal leak pressure&#x0D; Key words: LMA ProSeal™, LMA Supreme™, Oropharyngeal leak pressure; Airway; Aieway management&#x0D; Citation: Singh A, Kaur J, Kaur S, Gupta KK. Safety and efficacy of LMA Supreme™ vs. LMA ProSeal™ for ambulatory surgeries in adult patients. Anaesth. pain intensive care 2021;26(1):63-68.&#x0D; DOI: 10.35975/apic.v26i1.1769&#x0D; Received: June 02, 2021, Reviewed: December 13, 2021, Accepted: December 15, 2021

Comparison of Frequency of Complications of i-Gel and Laryngeal Mask Airway Supreme™ in Laparoscopic Cholecystectomy

Aim: To compare the frequency of complications of i-gel versus laryngeal mask airway supreme™ (LMA Supreme) in laparoscopic cholecystectomy. Study Design: Randomized Controlled Trial Place and Duration of Study: Department of Anesthesia, Jinnah Postgraduate Medical Institute Karachi from 16th September 2019 to 15th March 2020. Methodology: One hundred and fifty four patients having gallstones ≤5 in numbers (size &lt;2cm) on ultrasound for &gt;6 months requiring cholecystectomy and planned for elective list under general anesthesia of age ranges from 25-55 years of both gender were included. Patients with known or predicted difficult airway, oropharyngeal pathology, cervical spine fracture, GERD and hiatus hernia were excluded. In group A, airway was secured with i-gel while in group B, airway was secured with laryngeal mask airway supreme™. In all patients, anesthesia was given by one consultant anesthetist (at least 3 years 0f post-fellowship experience). All patients were followed by the researcher in the first 24 hours for presence or absence of dysphagia and sore throat. Results: The mean age was 34.78±6.30 years in group A and 34.38±6.37 years in group B. Majority of the patients 119 (77.27%) were between 25 to 40 years of age. There were 54 (35.06%) males and 100 (64.94%) were females with male to female ratio of ratio of 1:2.9. The complications of i-gel vs laryngeal mask airway supreme™ were found to be as follows; dysphagia on 0.0% vs 6.49% (p-value = 0.023) and sore throat in 3.90% vs 20.78% (p=0.001). Conclusion: The frequency of dysphagia and sore throat is less after i-gel use in laparoscopic cholecystectomy as compared to laryngeal mask airway supreme™. Keywords: General anesthesia, I-gel, Dysphagia

Laryngeal Mask Airway-SupremeTM (LMAS) in elective non-cardiac surgery: towards a more accurate quantification of difficult placement.

Laryngeal Mask Airway-SupremeTM (LMAS) in elective non-cardiac surgery: towards a more accurate quantification of difficult placement.

Laryngeal mask airway protector generates higher oropharyngeal leak pressures compared to the laryngeal mask airway supreme: A randomized clinical trial in the ambulatory surgery unit.

Background and Aims:The Laryngeal Mask Airway (LMA) Protector™ is one of the latest introduced supraglottic airway devices. It provides access and functional separation of the respiratory and digestive tracts. Compared to the LMA Supreme™, it has two digestive ports, one to provide suction in the pharyngeal region and one for gastric tube insertion. High oropharyngeal leak pressure is a marker for safe ventilation when using LMA devices. We hypothesized that oropharyngeal leak pressure of the LMA Protector™ is 5 cm H2O higher than the oropharyngeal leak pressure of the LMA Supreme™ at various cuff volumes. Secondary outcome measures were ease of insertion of both masks, fiberoptic confirmation of correct positioning, failures of insertion, presence of blood staining, sore throat, presence of air leak and insertion time.Material and Methods:American Society of Anesthesiologists (ASA) I-III patients aged >18 years, scheduled for elective minor ambulatory surgery under general anesthesia with a LMA were included. Patients were randomized in the LMA Protector™ or LMA Supreme™ group based on a computer-generated random sequence table. After general anesthesia induction, oropharyngeal leak pressures were measured.Results:Oropharyngeal leak pressures were significantly higher (P < 0.0001) for LMA Protector™ compared to LMA Supreme™ at different cuff volumes and a cuff pressure of 65 cm H2O. Insertion time was significantly higher for the LMA Protector™ (29 sec) [interquartile range (IQR) 23, 35] compared to the LMA Supreme™ (19 sec) (IQR 16, 22) (P < 0.0001). There were no statistically significant differences in ease of insertion (number of attempts for succesful positioning), failures of insertion, presence of blood staining, sore throat or presence of air leak.Conclusion:Oropharyngeal leak pressures were consistently higher (>5 cm H2O) for LMA Protector™ compared to LMA Supreme™. LMA Protector™, therefore, allows effective ventilation at higher airway pressures than LMA Supreme™.Trial Registration:http://clinicaltrials.gov.NCT03462550.

Comparison of clinical performance of laryngeal mask airway supremeTM and I-gelTM in patients undergoing elective non-laparoscopic surgeries

Supraglottic airway devices have a special niche for themselves with regards to airway management in modern anaesthesia practice. They have become a very good alternative to mask ventilation and tracheal intubation in elective surgeries and have an important place in the emergency settings. The single-use supraglottic airway devices I-gel™ and LMA-Supreme™ have been developed with the aim to overcome the limitations and improve the efficacy of currently available supraglottic airway devices like there airway sealing pressure, ease of placement but with discordant results with regards to airway sealing pressure, ease and success of placement and airway morbidity. The aim of this prospective, randomized trial was to evaluate these two airway devices in routine clinical practice. Materials and Methods: 80 patients (ASA grade1-2) were randomly allocated to two groups; Group I (I-gelTM; n=40) and Group S (LMA-SupremeTM; n=40). A size 3 or 4 (I-gelTM and LMA-SupremeTM) was used in patients and inserted by experienced anaesthesiologists who had 3 years’ experience and had performed 20 successful insertions with each device. First attempt success rate, time for insertion and airway sealing pressure of each device was measured. Airway sealing pressure with LMA-SupremeTM was measured at an intracuff pressure of 60cmH2O. Patients were enquired after surgery for the presence of any dysphagia, sore-throat or hoarseness of voice. Data were analyzed statistically using unpaired ‘t’ test and Chi-square test. A p value of < 0> Results: The first attempt success rate for I-gelTM was 92.5% and for LMA-SupremeTM was 87.5%. Ventilation was established in 19.7 seconds (range 14-24 seconds) in the I-gelTM group and in 24.2 seconds (range 19-29seconds) in LMA-SupremeTM group (pTM 23.2 cmH2O; LMA-SupremeTM 22.4 cmH2O; p>0.001). Conclusion: Both I-gelTM and LMA SupremeTM are disposable, latex-free devices which do not need any digital or introducer tool for insertion. They have

Effects of Peak Inspiratory Pressure-Guided Setting of Intracuff Pressure for Laryngeal Mask Airway Supreme™ Use during Laparoscopic Cholecystectomy: A Randomized Controlled Trial

Purpose To determine the effects of peak inspiratory pressure (PIP)-guided intracuff pressure (ICP) modulation of laryngeal mask airway (LMA) Supreme™ during laparoscopic cholecystectomy. Methods Totally 120 patients were randomly divided using computer-generated numbers into a control group (n = 60; ICP, 60 cmH2O) and a PIP group (n = 60), in which ICP was increased with 5 cmH2O each time from PIP level until no air leaks from the oropharynx. PIP, ICP, cuff volume (CV), oropharyngeal leak pressure (OLP) and leak fraction (LF) were recorded before and after pneumoperitoneum establishment. Postoperative pharyngolaryngeal complications (sore throat, dysphagia, pharyngeal hematoma, and dysphonia) were also recorded. Results Demographic data were similar in the two groups. The CV and ICP before and after pneumoperitoneum were significantly lower in the PIP group (CV: 15.6 ± 2.3 mL and 21.0 ± 2.6 mL; ICP: 14.3 ± 2.9 cmH2O and 20.5 ± 3.4 cmH2O) than in the control group (CV: 33.0 ± 2.8 mL and 32.8 ± 1.9 mL; ICP: 60.0 ± 0.1 cmH2O and 60.0 ± 0.1 cmH2O) (P < 0.05). Although OLP was lower in the PIP group (P < 0.05), the LF was similar in the two groups (P > 0.05). There were fewer postoperative pharyngolaryngeal complications in the PIP group (P < 0.05). Conclusions Compared with a fixed ICP of 60 cmH2O, PIP-guided ICP modulation during LMA Supreme™ use provided effective airway sealing at a lower CV and ICP, and produced fewer postoperative pharyngolaryngeal complications in patients undergoing laparoscopic cholecystectomy.

Comparison of laryngeal mask airway supremeTM as non-inflatable cuff device and self-pressurized air-QTM in children: Randomized controlled non-inferiority study.

Background: Supraglottic airway (SGA) device with non-inflatable cuff reduce the airway complications associated with cuff hyperinflation. The aim of the study is to determine whether the default setting of Supreme is as effective as the non-inflatable cuff devices. The oropharyngeal leak pressure was measured and compared between the Supreme and Air-Q, a typical non-inflatable cuff device. We hypothesized that the default setting of Supreme is non-inferior to the the Air-Q self-pressurized (SP) in respect to the oropharyngeal leak pressure.Methods: Eighty-four patients aged 1 to 7 years who were scheduled for general anesthesia, participated in the study. The patients were randomly assigned to Supreme group (n = 41) or Air-Q SP group (n = 43). We considered that the primary outcome, oropharyngeal leak pressure of Supreme group would be non-inferior to the Air-Q SP group, within 3 cmH2O. Other outcomes included tidal volume loss, difficulty of insertion, insertion time, and complications.Results: The oropharyngeal leak pressure of the Supreme and Air-Q SP was 19.9 ± 4.1 cm H2O and 17.4 ± 2.9 cm H2O, respectively. The mean differences of 2 devices (Air-Q SP—Supreme) were −2.5 cm H2O, (95% confidence interval [−4.0 to −0.9], P = .002). The upper CI was smaller than the non-inferiorty margin (3 cm H2O). This result suggested that the default setting of Supreme was superior to the Air-Q SP with respect to the oropharyngeal leak pressure. However, there were no significant differences in tidal volume loss over time, ease of device insertion score, insertion time, and complications.Conclusions: The Supreme can be used in the default setting in pediatric patients accordingly in terms of tolerable leak pressure and the stability for mechanical ventilation compared with Air-Q SP.

Positive end-expiratory pressure increases arterial oxygenation in elderly patients undergoing urological surgery using laryngeal mask airway in lithotomy position.

Elderly patients undergoing urological surgery in the lithotomy position may be vulnerable to perioperative hypoxemia. Positive end-expiratory pressure (PEEP) can improve arterial oxygenation. Although laryngeal mask airway (LMA) is widely utilized in urological surgery, it is not known how PEEP affects arterial oxygenation in these patients. We, therefore, evaluated the effect of PEEP on arterial oxygen partial pressure (PaO2) in elderly patients using LMA during urological surgery in the lithotomy position. Patients randomly received zero end-expiratory pressure (group Z, n = 34) or PEEP of 7 cmH2O (group P, n = 33). Ventilatory, respiratory, and haemodynamic variables were measured at 5min (T0), 30min (T1), and 60min (T2) after LMA Supreme™ (sLMA) insertion. The primary outcome was the difference of PaO2 at T2 between the two groups. Atelectasis score, the incidence of a significant leak, and complications associated with sLMA insertion were also evaluated. PaO2 at T2 was significantly higher in group P than in group Z (20.0 ± 4.9 vs. 14.7 ± 3.7kPa, P < 0.001). Atelectasis score at T2 was lower in group P than in group Z (5.3 ± 1.7 vs. 8.4 ± 2.3, P < 0.001). However, the incidence of a significant leak and complications associated with LMA insertion did not significantly differ between the two groups. PEEP can improve arterial oxygenation and reduce atelectasis in elderly patients using sLMA during urological surgery in the lithotomy position, suggesting that PEEP may be useful for elderly patients with an increased risk of perioperative hypoxemia when using sLMA.

A comparison of i-gel™ and Laryngeal Mask Airway Supreme™ during general anesthesia in infants.

BackgroundThe i-gel™ (i-gel) and Laryngeal Mask Airway Supreme™ (LMA Supreme) have been safely used in children. We compared the airway performance of the i-gel and LMA Supreme in infants undergoing general anesthesia.MethodsSixty infants with American Society of Anesthesiologists physical status I or II were randomly assigned to place either the i-gel or the LMA Supreme. The size 1 or 1.5 of each airway was selected by the weight of infants. The primary outcome variable was oropharyngeal leak pressure (OLP). We also assessed insertion success rate, insertion time, fiberoptic view of the larynx, airway quality, airway manipulations, and perioperative complications.ResultsDemographic data did not differ between the two groups. Insertion success rate was similar in both groups. OLP for the i-gel (26.0 ± 3.8 cmH2O) was higher than for the LMA Supreme (23.7 ± 3.2 cmH2O) (P = 0.016). Insertion time for the i-gel (16.4 ± 2.8 s) was shorter than for the LMA Supreme (18.5 ± 2.7 s) (P = 0.002). There were no differences in fiberoptic view of the larynx, airway quality, airway manipulations, and complications between the two groups.ConclusionsThis study demonstrated that the i-gel and LMA Supreme provided a similar performance of airway in infants. Compared with the LMA Supreme, the i-gel provided shorter insertion time and higher OLP in infants.

Comparison of oropharyngeal leak pressure of air-Q™, i-gel™, and laryngeal mask airway supreme™ in adult patients during general anesthesia: A randomized controlled trial.

Study Objective:Various randomized controlled trials and a meta-analysis have compared i-gel™ and laryngeal mask airway Supreme™ (LMA-S™) in adult patients and found that both the devices provided equivalent oropharyngeal leak pressure (OLP). However, no randomized controlled trial has compared air-Q™ with i-gel™ and LMA-S™ in adult patient. Hence, we designed this study to compare air-Q™ with LMA-S™ and i-gel™ in adult patients.Materials and Methods:A total of 75 adult patients of the American Society of Anesthesiologists physical status I/II of both sexes, between 18 and 60 years, were included in this prospective randomized controlled trial conducted in a tertiary care center. Randomization of patients was done in three equal groups according to the insertion of supraglottic airway device by a computer-generated random number sequence: group air-Q™ (n = 25), group i-gel™ (n = 25), and group LMA-S™ (n = 25). Primary outcome of this study was OLP. We also recorded time for successful placement of device, ease of device insertion, number of attempts to insert device, and ease of gastric tube insertion along with postoperative complications.Results:The mean ± standard deviation OLP of air-Q™, i-gel™, and LMA-S™ was 26.13 ± 4.957 cm, 23.75 ± 5.439 cm, and 24.80 ± 4.78 cm H2O (P = 0.279). The first insertion success rate for air-Q™, i-gel™, and LMA-S™ was 80%, 76%, and 92%, respectively (P = 0.353). The insertion time of air-Q™, i-gel™, and LMA-S™ was 20.6 ± 4.4, 14.8 ± 5.4, and 15.2 ± 4.7 s, respectively (P = 0.000). Time taken for air-Q™ insertion was significantly higher than time taken for i-gel™ (mean difference 5.8 s, P < 0.0001) and LMA-S™ (mean difference 5.4 s, P = 0.0001) insertion. Postoperative complications were similar with all three devices.Conclusions:We concluded that air-Q™, i-gel™, and LMA-S™ were equally efficacious in terms of routine airway management in adult patients with normal airway anatomy.

Comparison of i-gel™ and Laryngeal Mask Airway Supreme™ in Different Head and Neck Positions in Spontaneously Breathing Pediatric Population.

Background:Although the advantages of ventilation with i-gel™ and laryngeal mask airway Supreme (LMA-Supreme™) has been well documented, they are still under debate for surgeries requiring flexion and extension of neck such as thyroid surgery, tonsillectomy, and neck exploration. Hence, we conducted a study to demonstrate the effect of neck flexion and extension in spontaneously breathing anesthetized pediatric patients utilizing i-gel™ and LMA-Supreme™.Methods:A prospective, randomized comparative study was conducted on sixty children, thirty each in i-gel™ and LMA-Supreme™ group. Oropharyngeal leak pressure (OPLP), fiberoptic view of vocal cords, and exhaled tidal volume were evaluated in neutral, flexion, and extension neck positions in spontaneously breathing children.Results:OPLP for i-gel™ was found to be significantly higher in flexion (29.00 ± 1.95 cmH2O, P < 0.001) and lower in extension (21.07 ± 2.08 cmH2O, P < 0.001) as compared to neutral (24.67 ± 2.08 cmH2O). Similar results were observed for LMA-Supreme™ which showed significantly higher OPLP in flexion (24.73 ± 2.26, P < 0.001 respectively) and lower in extension (18.67 ± 1.42 cmH2O, P < 0.001) as compared to neutral (20.87 ± 1.80 cmH2O). Worsening of fiberoptic view occurs for i-gel™ and LMA-Supreme™ in flexion (10/12/5/3/0 and 11/14/2/2/1, P < 0.05) as compared to neutral position (17/10/2/1/0 and 15/12/1/1/1), respectively. Significant change did not occur in extension. Ventilation worsening occurred in flexion as compared to neutral position evidenced by significant decrease in exhaled tidal volume (92.90 ± 11.42 and 94.13 ± 7.75 ml, P < 0.05) as compared to neutral (100.23 ± 12.31 and 101.50 ± 8.26 ml) for i-gel™ and LMA-Supreme™, respectively.Conclusion:Neck flexion caused a significant increase in leak pressure in both i-gel™ and LMA-Supreme™. With deterioration of fiberoptic view and ventilation, both devices should be used cautiously in pediatric patients in extreme flexion.

Greater palatine nerve neuropraxia after laryngeal mask insertion: A rare occurrence.

With the more frequent use of the laryngeal mask airway (LMA) over endotracheal tubes for general anaesthesia, various cranial nerve injuries have been reported recently. We report a rare occurrence of greater palatine nerve (GPN) palsy subsequent to the use of LMA Supreme™ in a young female scheduled for hand surgery. Although the exact mechanism of a nerve injury is still a matter of further research, we postulate pressure neuropraxia of GPN as a causative factor in the development of numbness over the hard palate after the removal of LMA in the post operative period.

Comparison of Laryngeal Mask Airway Supreme(TM) Versus Unique(TM) in Edentulous Geriatric Patients.

It is more difficult to perform bag-mask ventilation in edentulous patients than in patients with intact dentition. The laryngeal mask airway (LMA) provides a better alternative to the standard face mask if the facial contours of the patient are not suited for the standard face mask. We aimed to compare these two different LMAs in edentulous geriatric patients. Edentulous patients aged ≥65 years of American Society of Anesthesiologists physical status I-III were included in the study. They were randomly assigned to Supreme group (n=30) and Unique group (n=30). Success of first insertion attempt, ease and time of insertion and oropharyngeal leak pressure were recorded. The success rate of the first insertion attempt was higher in the Supreme group than in the Unique group (86.6 and 73.3%, respectively; p=0.04). Time of insertion was similar (10.04 s and 11.87 s, respectively) and insertion was easy in 90% and 100% of patients, respectively. Oropharyngeal leak pressures were measured as 20.56-cm H2O and 17.10-cm H2O for LMA Supreme™ and LMA Unique™, respectively. The efficacy and safety in both groups were comparable in edentulous geriatric patients during short surgical procedures. Even the success rate of insertion with both was lower than that mentioned in the literature; the success of insertion at the first attempt was superior with the LMA Supreme™ in our edentulous study group.

A randomized comparison of the Laryngeal Mask Airway Supreme™ and Laryngeal Mask Airway Unique™ in infants and children: does cuff pressure influence leak pressure?

Summary Background The cuff pressure for optimal airway sealing with first-generation laryngeal mask airway has been shown to be 40 cm H2O in children. Currently, there are no data regarding the ideal intracuff pressure for the laryngeal mask airway Supreme (Supreme) in children. Objectives To compare the clinical performance of the laryngeal mask airway supreme with the laryngeal mask airway unique in infants and children. Materials and methods One hundred eighty children were assigned to receive either a Supreme or a laryngeal mask airway-U. We hypothesized higher airway leak pressure with the Supreme at both 40 cm H2O and 60 cm H2O, when compared with the laryngeal mask airway-U. Ease and time of insertion, insertion attempts, fiber optic examination, quality of airway, efficacy of mechanical ventilation, success of gastric tube placement (Supreme), incidence of gastric insufflation, and complications were also assessed. Results Airway leak pressure at an intracuff pressure of 60 cm H2O for the Supreme was 17.4 (5.2) vs laryngeal mask airway-U at 18.4 (6.6) cm H2O and did not differ when compared to an intracuff pressure of 40 cm H2O for both devices; Supreme at 17.2 (5) vs laryngeal mask airway-U at 17.7 (6) cm H2O. The laryngeal mask airway-U was associated with higher first-attempt success rates. The Supreme was associated with less gastric insufflation than the laryngeal mask airway-U. Conclusions Intracuff pressures of 40 cm H2O may be sufficient for the Supreme in children, and there may be no added benefit of an intracuff pressure of 60 cm H2O, as leak pressures were similar. The Supreme may be preferred over the laryngeal mask airway-U for its lower rates of gastric insufflation and provision for gastric access when mechanical ventilation is utilized.

Intracuff pressures in ProSeal and Supreme airways

AnaesthesiaVolume 69, Issue 2 p. 183-183 CorrespondenceFree Access Intracuff pressures in ProSeal and Supreme airways A. Philip, A. Philip [email protected] Leicester Royal Infirmary, Leicester, UKSearch for more papers by this authorV. Kaushik, V. Kaushik Leicester Royal Infirmary, Leicester, UKSearch for more papers by this authorM. Mushambi, M. Mushambi Leicester Royal Infirmary, Leicester, UKSearch for more papers by this author A. Philip, A. Philip [email protected] Leicester Royal Infirmary, Leicester, UKSearch for more papers by this authorV. Kaushik, V. Kaushik Leicester Royal Infirmary, Leicester, UKSearch for more papers by this authorM. Mushambi, M. Mushambi Leicester Royal Infirmary, Leicester, UKSearch for more papers by this author First published: 20 January 2014 https://doi.org/10.1111/anae.12569Citations: 1 No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesiacorrespondence.com. AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat We read with interest the article by Anand et al. 1 comparing intracuff pressures between the ProSeal® and Supreme® laryngeal mask airways (LMAs) and should like the authors to clarify some issues that are not clear in their article: Did the authors standardise tidal volumes and peak airway pressures for all their patients? The authors mention that the initial intracuff readings were 60 cmH20 in both groups. Were the cuffs intentionally inflated to that value? If so, the authors chose to inflate the cuffs to the upper limit of the manufacturers' recommendations, which is usually unnecessary since an adequate seal can be achieved at lower cuff pressures. Silicone cuff-based ProSeal LMAs are re-used after sterilisation. Did the authors factor this into their standardisation, i.e. a ProSeal LMA that has been sterilised 30 times will presumably allow more diffusion of nitrous oxide than one that has been sterilised, say, 10 times or less? In Zhang et al.'s study 2, referred to by Anand and colleagues in their study, oropharyngeal leak pressure was determined by closing the expiratory valve at a fixed gas flow of 3 l.min−1 and noting the pressure in the circuit at which an audible leak is heard over the mouth. It is not clear how Anand et al. checked the oropharyngeal leak pressure; was it using a similar method? Anand et al. recommend that cuff pressure should be monitored when ProSeal LMAs are used during general anaesthesia involving nitrous oxide. Recommendations to monitor cuff pressures in LMAs should apply to all LMAs, and not just to ProSeal LMAs. References 1Anand LK, Singh M, Kapoor D, Goel N. Intracuff pressure comparison between ProSeal® and Supreme® laryngeal mask airways. Anaesthesia 2013; 68: 1202– 3. 2Zhang L, Seet E, Mehta V, et al. Oropharyngeal leak pressure with the laryngeal mask airway supreme™ at different intracuff pressures: a randomized controlled trial. Canadian Journal of Anesthesia 2011; 58: 624– 9. Citing Literature Volume69, Issue2February 2014Pages 183-183 ReferencesRelatedInformation

A randomized comparison of the laryngeal mask airway supreme™ and laryngeal mask airway unique™ in infants and children: does cuff pressure influence leak pressure?

The cuff pressure for optimal airway sealing with first-generation laryngeal mask airway has been shown to be 40 cm H(2)O in children. Currently, there are no data regarding the ideal intracuff pressure for the laryngeal mask airway Supreme (Supreme) in children. To compare the clinical performance of the laryngeal mask airway supreme with the laryngeal mask airway unique in infants and children. One hundred eighty children were assigned to receive either a Supreme or a laryngeal mask airway-U. We hypothesized higher airway leak pressure with the Supreme at both 40 cm H(2)O and 60 cm H(2)O, when compared with the laryngeal mask airway-U. Ease and time of insertion, insertion attempts, fiber optic examination, quality of airway, efficacy of mechanical ventilation, success of gastric tube placement (Supreme), incidence of gastric insufflation, and complications were also assessed. Airway leak pressure at an intracuff pressure of 60 cm H(2)O for the Supreme was 17.4 (5.2) vs laryngeal mask airway-U at 18.4 (6.6) cm H(2)O and did not differ when compared to an intracuff pressure of 40 cm H(2)O for both devices; Supreme at 17.2 (5) vs laryngeal mask airway-U at 17.7 (6) cm H(2)O. The laryngeal mask airway-U was associated with higher first-attempt success rates. The Supreme was associated with less gastric insufflation than the laryngeal mask airway-U. Intracuff pressures of 40 cm H(2)O may be sufficient for the Supreme in children, and there may be no added benefit of an intracuff pressure of 60 cm H(2)O, as leak pressures were similar. The Supreme may be preferred over the laryngeal mask airway-U for its lower rates of gastric insufflation and provision for gastric access when mechanical ventilation is utilized.

Prolonged use of the LMA Supreme™

To the Editor, The LMA Supreme (The Laryngeal Mask Company Limited, Le Rocher, Victoria, Mahe, Seychelles) is a disposable extraglottic laryngeal mask airway that features high airway sealing pressures and a channel for gastric decompression. We report the use of an LMA Supreme in an unexpected prolonged surgery. The patient gave written consent for the publication of this case report. A 74-yr-old male (weight 68 kg, height 168 cm) with a history of allergic rhinitis was admitted for re-intervention of a mixed tumour of the parotid gland. The physical examination and laboratory tests were normal, and no criteria were found to predict difficult airway management. Expected duration of surgery was two hours. The neurophysiologist requested avoidance of neuromuscular blockade and halogenated anesthetics to allow monitoring of facial nerve branches. Standard hemodynamic variables, urine output, and bispectral index (BIS) were monitored. Anesthesia was induced with propofol 2 mg kg and maintained with a continuous infusion of propofol (4-6 mg kg hr) and remifentanil (0.2-0.4 lg kg min), adjusted for a BIS target value 60. Nitrous oxide was not used. A size-4 LMA Supreme was inserted and the cuff was inflated with 20 mL of air. Volume-controlled ventilation was initiated with the following parameters: tidal volume 6 mL kg; inspiratory:expiratory ratio 1:2; and respiratory frequency 12 breaths min. Peak inspiratory pressure was 16 cm H2O during the procedure and the capnographic wave was normal. Once the airway sealing was assessed, we placed a 16G orogastric drain tube, decompressed the patient’s stomach, and connected the drain tube to a drainage bag on the floor. Due to dissection difficulties, the surgery lasted for seven hours and 20 min, and we left the LMA Supreme in place during all this time. There was no air leakage throughout the surgery, and the drainage bag collected only a few millilitres of bilious fluid. We administered dexamethasone 4 mg, acetaminophen 1 g, and dexketoprofen 50 mg iv before the end of surgery. We removed the LMA Supreme with the patient awake and breathing spontaneously. History and physical examination of the patient in the recovery room immediately after surgery and before discharge ruled out any side effects relating to prolonged use of the LMA Supreme. Most reported problems associated with the laryngeal mask airway (LMA) are related to the misuse of the device. Complications, such as mucosal ischemic injury, gastric insufflation, regurgitation, and aspiration, appear to be time-dependent. As a result, LMAs have been used chiefly for short surgical procedures. The risk of mucosal injury increases with cuff volume due to increased mucosal pressure. A well-placed LMA Supreme provides adequate airway sealing with minimal intracuff volume, which is important for prolonged use. A 20-mL volume of air for a size-4 LMA Classic does not produce elevated pressure on the pharyngeal mucosa, but we have a lack of corresponding data for the LMA Supreme. As we had no possibility of measuring intracuff pressure, we used 20 mL of air with good sealing pressure ([ 25 cm H2O). Although data are lacking on mucosal pressure applied by the LMA Supreme, it appears that a 20-mL volume is safe for prolonged use without nitrous oxide. Incorporating a drain tube with the LMA Supreme minimizes the likelihood of gastric insufflation and allows a route to vent regurgitated gastric contents. Publications investigating a safe time limit M. Kammah, MD (&) C. Anez, MD, PhD Servicio de anestesiologia y reanimacion, Hospital Universitario Joan XXIII, Rambla President Lluis Company, Tarragona, Spain e-mail: maryemane@gmail.com