LMA SupremeTM Research Articles

A randomised, non‐crossover study of the GuardianCPV™ Laryngeal Mask versus the LMA Supreme™ in paralysed, anaesthetised female patients

We investigated the hypothesis that the oropharyngeal leak pressure would differ between the GuardianCPV™ and the LMA Supreme™ in anaesthetised patients. We randomly assigned 120 patients to receive either the GuardianCPV or the LMA Supreme for airway management. Oropharyngeal leak pressure was measured during cuff inflation from 0 to 40 ml in 10-ml steps. In addition, intracuff pressure, fibreoptic position of the airway and drain tube, device insertion success, ventilation success, blood staining and airway morbidity were determined. Mean (SD) oropharyngeal leak pressures for clinically acceptable cuff volumes of 20-40 ml were 31 (7) cmH2O for the GuardianCPV and 27 (7) cmH2O for the LMA Supreme (p < 0.0001); mean (SD) intracuff pressures were 68 (33) cmH2O and 88 (43) cmH2O (p < 0.0001), respectively. We found no differences in device insertion success, ventilation success, fibreoptic position of the airway and drain tube, blood staining or airway morbidity. We conclude that the oropharyngeal leak pressure is better for the GuardianCPV than for the LMA Supreme in anaesthetised patients.

A Comparative Study of Two Disposable Supraglottic Devices in Diagnostic Laparoscopy in Gynecology

ABSTRACT Introduction This prospective study compares the efficacy of two disposable supraglottic airway devices with separate gastric access and integral bite block, the inflatable cuff of the LMA SupremeTM against the noninflatable i-gelTM cuff in providing an adequate seal for laparoscopic surgery. Materials and methods Ninety women of ASA grade I and II undergoing diagnostic laparoscopy with Trendelenburg position were randomly allocated to receive either size 3 LMA Supreme or i-gel. Induction and maintenance protocols were similar and patients were not paralyzed. We compared the airway leak pressure, ease and time to insert the device and a 10 FG nasogastric tube through it, and to note complications if any. Results There was no difference in airway leak pressure between the two devices (24.4 ± 4.0 vs 23.6 ± 3.8 cm H2O, p &gt; 0.05). Forty-one (91%) LMA Supremes and forty (88.8%) i-gels were successfully inserted on the first attempt, with similar ease, and comparable times (13.8 ± 4.9 sec for LMA Supreme vs 14.5 ± 6.7 sec for i-gel; p &gt; 0.05). Gastric tube insertion was easier and achieved more quickly with LMA Supreme compared to i-gel (9.0 ± 3.1 sec vs 14.3 ± 7.5 sec, respectively; p &lt; 0.01), but clinical significance of this finding is questionable. There was blood on removal of four LMA Supremes and three i-gel. Four patients in the LMA Supreme group and one patient in the i-gel group experience mild postoperative sore throat. Conclusion Both LMA Supreme and i-gel are equally effective ventilator devices for diagnostic gynecological laparoscopic procedures. How to cite this article Chattopadhyay S, Goswami S. A Comparative Study of Two Disposable Supraglottic Devices in Diagnostic Laparoscopy in Gynecology. J South Asian Feder Obst Gynae 2013;5(3):124-128.

Magnetic resonance imaging study of the in vivo position of the extraglottic airway devices i-gel™ and LMA-Supreme™ in anaesthetized human volunteers

Exact information on the anatomical in situ position of extraglottic airway (EGA) devices is lacking. We used magnetic resonance imaging (MRI) to visualize the positions of the i-gel™ and the LMA-Supreme™ (LMA-S) relative to skeletal and soft-tissue structures. Twelve volunteers participated in this randomized, prospective, cross-over study. Native MRI scans were performed before induction of anaesthesia. Anaesthesia was induced, and the two EGAs were inserted in a randomized sequence. Their positions were assessed functionally, optically by fibrescope, and with MRI scans of the head and neck. The LMA-S protruded deeper into the upper oesophageal sphincter than the i-gel™ (P<0.001). Both devices reduced the area of the glottic aperture (P<0.001), and the LMA-S had the largest effect (P=0.049). The i-gel™ significantly compressed the tongue (P<0.001). Both devices displaced the hyoid bone ventrally (P<0.001); the i-gel™ to a greater degree (P=0.029). The fibreoptically determined position of the bowl of the devices was identical. The LMA-S and i-gel™ differ significantly with regard to in situ position and spatial relationship with adjacent structures assessed by MRI, despite similar clinical and fibreoptical findings. This could be relevant with regard to risk of aspiration, glottic narrowing, and airway resistance and soft-tissue morbidity.

The effect of a cervical collar on the seal pressure of the LMA Supreme™: a prospective, crossover trial

For personnel inexperienced in airway management, supraglottic airway devices may be the first choice in an emergency. Changing head position is known to reduce the seal pressure of a laryngeal mask airway. The aim of this study was to investigate whether the use of a cervical collar improves the stability of airways secured with the LMA Supreme™ (The Laryngeal Mask Company Limited, Mahé, Seychelles). In this crossover trial, the primary endpoint was the difference in the seal pressure of the LMA Supreme in anaesthetised patients in maximum passive extension of the neck, with and without a cervical collar. The median (IQR [range]) seal pressure was 18 (13.8-22.1 [0-30]) cmH(2) O in maximum passive extension without a cervical collar. With a cervical collar in place, the seal pressure increased to 28 (22.8-30 [17-30]) cmH(2) O (p<0.001). In the neutral head position, the seal pressure was 22 (17.6-24.5 [12-30]) cmH(2) O without and 27 (22-30 [12-30]) cmH(2) O with a cervical collar in place (p<0.001). We found that a cervical collar stabilises the airway with an LMA Supreme in place and we recommend this combination for (pre-hospital) emergency cases.

Randomized comparison of the i-gel™, the LMA Supreme™, and the Laryngeal Tube Suction-D using clinical and fibreoptic assessments in elective patients

BackgroundThe i-gel™, LMA-Supreme (LMA-S) and Laryngeal Tube Suction-D (LTS-D) are single-use supraglottic airway devices with an inbuilt drainage channel. We compared them with regard to their position in situ as well as to clinical performance data during elective surgery.MethodsProspective, randomized, comparative study of three groups of 40 elective surgical patients each. Speed of insertion and success rates, leak pressures (LP) at different cuff pressures, dynamic airway compliance, and signs of postoperative airway morbidity were recorded. Fibreoptic evaluation was used to determine the devices’ position in situ.ResultsLeak pressures were similar (i-gel™ 25.9, LMA-S 27.1, LTS-D 24.0 cmH2O; the latter two at 60 cmH2O cuff pressure) as were insertion times (i-gel™ 10, LMA-S 11, LTS-D 14 sec). LP of the LMA-S was higher than that of the LTS-D at lower cuff pressures (p <0.05). Insertion success rates differed significantly: i-gel™ 95%, LMA-S 95%, LTS-D 70% (p <0.05). The fibreoptically assessed position was more frequently suboptimal with the LTS-D but this was not associated with impaired ventilation. Dynamic airway compliance was highest with the i-gel™ and lowest with the LTS-D (p <0.05). Airway morbidity was more pronounced with the LTS-D (p <0.01).ConclusionAll devices were suitable for ventilating the patients’ lungs during elective surgery.Trial registrationGerman Clinical Trial Register DRKS00000760

Use of intubation introducers through a supraglottic airway to facilitate tracheal intubation: a brief review

This article is a narrative review regarding the usage and effectiveness of introducers or catheters to facilitate tracheal intubation through a supraglottic airway (SGA) as an alternative intubation technique in normal and difficult airway management. Relevant articles were obtained through Medline (1948-July 2011). The articles were subsequently cross-referenced for additional literature, and only articles published in English were included. In this review, we consider 32 reports using the LMA Classic™, LMA Unique™, LMA ProSeal™, LMA Supreme™, AuraOnce™, and i-gel™ as SGA conduits for intubation. In 13 articles, the use of an Aintree Intubation Catheter was described as an intubation introducer and resulted in high success rates in both elective and emergent situations. Eight studies used a guidewire exchange catheter technique. Although blind intubation using a guidewire resulted in a high failure rate, these studies found that using a bronchoscope improved successful intubation. Ten studies showed that insertion of a gum elastic bougie with a bronchoscope as an intubation introducer has high success rates compared with blind bougie insertion. One article described the use of a small endotracheal tube as an intermediary for tracheal intubation. In failed intubation scenarios, supraglottic airways, such as the LMA Classic™ or LMA ProSeal™ can serve as a conduit for tracheal intubation. A number of techniques using introducers or catheters can facilitate the insertion of an adequately sized endotracheal tube, particularly guided by a bronchoscope. Usage of introducers or catheters through a supraglottic airway may be a useful alternative intubation technique in difficult airway management.

The LMA Supreme™ in 700 parturients undergoing Cesarean delivery: an observational study

The LMA Supreme™ (SLMA) is a single-use supraglottic device that provides a good seal for positive pressure ventilation. It has a double aperture design that facilitates the introduction of an orogastric tube to aspirate gastric contents. This observational study evaluated the role of the SLMA in parturients undergoing Cesarean delivery under general anesthesia. Non-obese parturients with at least four hours of fasting and antacid prophylaxis scheduled for uncomplicated Cesarean delivery were recruited from June 2009 through May 2010 at the Quanzhou Women's and Children's Hospital, China. We recorded the number of SLMA insertion attempts, the time to effective ventilation, the incidence of aspiration, and other anesthetic and obstetric outcomes. Postoperatively, we noted the presence of blood on the SLMA, postoperative sore throat, and patient satisfaction. Analysis included comparison of results between parturients having elective and urgent Cesarean delivery. We recruited 700 parturients (576 elective, 124 urgent). Mean (standard deviation) body mass index was 25.6 (2.5) kg·m(-2). All SLMA insertions were successful, with 686 (98%) inserted on first attempt and a time to effective airway of 19.5 (3.9) sec. We maintained ventilation and oxygenation in all parturients with a good seal and there was no evidence of aspiration. Eighteen parturients (2.6%) had blood on the SLMA upon removal, 24 (3.4%) had sore throat, and patient satisfaction was 85 (7)%. These results were similar in elective and urgent cases. In a carefully selected group of parturients, the SLMA is a useful alternative to tracheal intubation for Cesarean delivery, providing effective ventilation and a low incidence of side effects or complications.

The Laryngeal Mask Airway Supreme™: safety and efficacy during gynaecological laparoscopic surgery

AbstractBackground: Laryngeal Mask Airway Supreme™ (LMA Supreme™) is a new single-use polyvinyl chloride supraglottic device that offers gastric access. To date, studies that have tested the LMA Supreme™) for use in laparoscopic surgery have been reported. We present the largest evaluative study that describes the use of this mask for anaesthesia in gynaecological laparoscopic surgery.Method: Hospital ethics board approval was obtained, and 140 fasted patients undergoing elective gynaecological laparoscopy were prospectively studied. We evaluated the ease of insertion of the device and the drain tube, the oropharyngeal leak pressure (OLP), incidence of postoperative sore throat, and other adverse events.Results: Insertion of the LMA Supreme™ was successful in all patients (first attempt, n = 123; second attempt, n = 16; and third attempt, n = 1). Gastric tube insertion was successful in all patients (easy, n = 135; difficult, n = 5). Initial mechanical ventilation was adequate in almost all cases. Mean OL...

A randomised comparison of the LMA Supreme™ and LMA ProSeal™ in children

We conducted a randomised trial comparing the size-2 LMA Supreme™ with the LMA ProSeal™ in 60 children undergoing surgery. The outcomes measured were airway leak pressure, ease and time for insertion, fibreoptic examination, incidence of gastric insufflation, ease of gastric tube placement, quality of the airway during anaesthetic maintenance and complications. There were no statistically significant differences between the LMA Supreme and LMA ProSeal in median (IQR [range]) insertion time (12 (10-15 [7-18]) s vs 12 (10-13 [8-25]) s; p = 0.90), airway leak pressures (19 (16-21 [12-30]) cmH(2) O vs 18 (16-24 [10-34]) cmH(2) O; p = 0.55), fibreoptic position of the airway or drain tube, ease of gastric access and complications. Both devices provided effective ventilation requiring minimal airway manipulation. The LMA Supreme can be a useful alternative to the LMA ProSeal when single-use supraglottic devices with gastric access capabilities are required.

LMA Supreme™ vs i‐gel™– a comparison of insertion success in novices

Two new supraglottic airway devices, the LMA Supreme™ (LMA) and the i-gel™, offer potential benefits when inserted by inexperienced operators. This study compared the insertion success rate and ventilation profile between the LMA Supreme and the i-gel when inserted by operators without previous airway management expertise. Following a short lecture and manikin training, airway novices were randomly allocated to insert either the LMA Supreme or the i-gel into 80 patients undergoing breast surgery. The primary outcome was first-time success rate, and secondary outcomes were overall success rate, insertion time, airway leak pressure, tidal volume during pressure controlled ventilation at 17 cmH(2)O, and adverse events. First-time insertion success rate was significantly higher for the LMA Supreme than the i-gel (30/39 (77%) vs 22/41 (54%); p = 0.029). Significantly more placement failures occurred with the i-gel (6 vs 0, p = 0.025). Mean (SD) leak pressure (29 (8) vs 23 (11) cmH(2)O, p = 0.007) and expired tidal volume (PCV 17 cmH(2)O) (785 (198) vs 654 (91), p = 0.001) were significantly greater with the LMA Supreme than with the i-gel, respectively. More patients complained of pharyngolaryngeal pain with the LMA Supreme than with the i-gel (17/39 (44%) vs 8/41 (20%); p = 0.053). We found better first time success rate, fewer failures, and a better seal with the LMA Supreme compared with the i-gel, indicating that the LMA Supreme may be preferable for emergency airway use by novices.

Directly measured mucosal pressures produced by the i‐gelTM and laryngeal mask airway SupremeTM in paralysed anaesthetised patients

The i-gel™ and LMA Supreme™ are extraglottic airway devices with non-inflatable and inflatable cuffs, respectively. We hypothesised that directly measured mucosal pressures would differ between these devices in anesthetised paralysed patients. Thirty patients were randomly allocated to receive one of these two devices. Four pressure sensors were attached to all airway devices used to measure mucosal pressure at the base of the tongue, the distal oropharynx, the hypopharynx and the pyriform fossa. At these four places, median (IQR [range]) i-gel mucosal pressures were 8.0 (2.7-10.7 [0-26.7]), 5.0 (2.7-7 [1.0-37.3]), 9.3 (2.7-13.3 [0-22.7] and 8.0 (2.7-10.7 [0-25.3]) cmH(2)O, respectively, and for the LMA Supreme, these were 5.0 (0.5-8.0 [0-33]), 4.0 (1.3-9.3 [0-24]), 10.7 (4-17.3 [0-26.7]) and 8.0 (0-10.7 [0-36]) cmH(2)O, respectively. Mucosal pressures were low and similar for both devices. The LMA Supreme mucosal pressures were higher in the hypopharynx than in the distal oropharynx (p = 0.04) and base of the tongue (p = 0.011). There were no pressure differences between the locations for the i-gel.

Investigating the Fluid Seal of Supraglottic Airway Devices in Humans Using Indicator Dye via the Drainage Tube: A Potential Roadmap for Future Studies

Background: The fluid seal of supraglottic airway devices (SGA) protects the airway from fluid contamination. We evaluated the suitability of indicator dye placement in the upper digestive tract of anesthetized patients combined with fiberoptical tracing to investigate the fluid seal of SGA. Methods: Patients swallowed a capsule of indigo carmine green (ICG) prior to induction of anaesthesia. After induction of anesthesia, one of two different SGA (either an i-GelTM or an LMA-SupremeTM (LMA-S)) was inserted after randomization. Methylene blue stained normal saline was injected through the proximal opening of drainage tube during mechanical ventilation as well as spontaneous breathing. We monitored regurgitation of ICG with a flexible fiberscope (FO) inserted through the drainage tube and checked for the appearance of methylene blue in the mask bowl with the FO inserted through the airway tube. Results: In thirty-six patients with an i-GelTM and 37 with a LMA-S no regurgitation of ICG was observed at the level of the upper oesophageal sphincter (UES). Methylene blue stained saline was not visible in any patient during pressure-controlled ventilation, but was detected in two of the 36 patients with the i-GelTM during spontaneous breathing. Conclusion: Instilling dye through the drainage tube of SGA models with a built-in drainage tube represents a useful method to examine and to compare the fluid seal of different SGA. Our protocol presented in this study proved to be an easy and reproducible approach for future studies. Furthermore, the clinical results gained during this evaluation highlight the necessity for further investigations regarding the fluid seal competencies of SGAs in humans under clinical conditions.

Tracheal intubation in an unanticipated difficult airway by advancing a bronchoscope and a tracheal tube introducer through a LMA Supreme™

To the Editor, We report a case involving a patient with an unanticipated difficult airway in whom tracheal intubation was achieved uneventfully by advancing a bronchoscope and a tracheal tube introducer through a LMA Supreme. The patient’s written consent was obtained for this publication. A 70 kg, 52-yr-old woman was scheduled for nephrolithotomy. She had an adequate mouth opening, a normal thyromental distance, and a Mallampati class 3 airway. Anesthesia was induced with midazolam, fentanyl, propofol, and atracurium iv. Adequate mask ventilation was achieved. Direct laryngoscopy with a Macintosh #3 blade showed a Cormack-Lehane Grade 3 laryngeal view and tracheal intubation failed in two attempts. After further mask ventilation, oral bronchoscopic (5.0 mm outer diameter [OD]) intubation was attempted but failed due to poor visualization from blood and secretions. The SPO2 decreased to 90%. A size 4 LMA Supreme (LMA International, Singapore) was inserted with a satisfactory capnographic waveform and SPO2 returned to 100%. A decision was then made to intubate the patient’s trachea via the LMA Supreme. A pediatric bronchoscope (Olympus BF XP60, 2.8 mm OD) operated by an anesthesiologist and a solid tracheal tube introducer with a coude tip (5 mm OD, Well Lead Medical, China) operated by a second anesthesiologist were advanced through the airway lumen of the LMA Supreme into the pharynx (Figure). The tracheal tube introducer was advanced under bronchoscopic guidance through the glottis into the trachea and positioned 3 cm above the carina. The bronchoscope and LMA Supreme were then removed while keeping the tracheal tube introducer in position. A 7.0 mm internal diameter (ID) tracheal tube was railroaded over the tracheal tube introducer and into the trachea, and positioning of the tracheal tube was confirmed by capnography. Ten minutes after the completion of surgery, the patient was awakened and the tracheal tube was removed. The patient’s recovery was uneventful. After failed attempts at tracheal intubation, a supraglottic airway may be inserted for lung ventilation while awaiting alternative airway equipment. In lieu of removing the supraglottic airway to attempt alternative intubation techniques, it can be kept in situ as a conduit for tracheal intubation. Ventilation is not interrupted and secretions and blood are kept posterior to the supraglottic airway allowing a clear path to the larynx. The LMA Supreme is a single-use variant of the LMA Proseal. Its curved shaft consists of a double lumen, i.e., a central lumen for gastric access within an airway lumen for respiratory tract access. Like the LMA Classic, it is difficult to pass an adequately sized endotracheal tube (ETT) directly through the LMA Supreme due to the airway luminal diameter. There are four techniques to achieve tracheal intubation with an adequately sized ETT, through the use of introducers or catheters, via the LMA Supreme. The four techniques utilize a small ETT, an Aintree Intubating Catheter, a guidewire, or a tracheal tube introducer. With the first technique, a small ETT (up to 6.0 mm ID) is mounted over a bronchoscope and inserted into the trachea through the LMA Supreme. Subsequently, an airway exchange catheter is inserted via the ETT, which is later exchanged for a full-sized ETT. Q.-J. Chu, MD X.-P. Han, MD First Affiliated Hospital, Zhengzhou University, Zhengzhou, China

Randomised Comparison of the LMA Supreme™ with the I-Gel™ in Spontaneously Breathing Anaesthetised Adult Patients

We compared the performance of the LMA Supreme (SLMA) with the I-Gel during anaesthesia in spontaneously breathing adult patients. Ninety patients with American Society of Anesthesiologists physical status I or II were studied in a prospective randomised controlled study. Our primary outcome measure was oropharyngeal leak pressure. We also compared the overall insertion success rate, ease of insertion, adequacy of ventilation and incidence of complications. The mean (SD), oropharyngeal leak pressure for the SLMA was 25.6 (5.1) cmH2O, which was greater than for the I-Gel 20.7 (5.9) cmH2O (P = 0.0001). The first attempt and overall insertion success rates were similar between the two groups (SLMA 97.8 and 97.8%; I-Gel 93.3 and 100%, P = 0.132). The SLMA was rated easier to insert than the I-Gel (P = 0.011), but the time taken for insertion (P = 0.433) was similar. The incidence of complications was low in both groups. The grade of fibreoptic view was better with the I-Gel than the SLMA (P = 0.001). We conclude that in adults with normal airways, the SLMA is easier to insert and provides a higher oropharyngeal leak pressure, but fibreoptic views are better with the i-gel.

The LMA Supreme™ laryngeal mask as an alternative to tracheal intubation in prolonged procedures

Department of Anaesthesiology and Intensive Care, St. Anne's University Hospital Brno, Brno, Czech Republic

In vitro study of magnetic resonance imaging artefacts of six supraglottic airway devices

We investigated the artefacts created during magnetic resonance imaging by five different laryngeal mask airways: the Classic (cLMA); the LMA ProSeal; the LMA Unique; the Ambu Disposable Laryngeal Mask; the LMA Supreme; and one other supraglottic airway device, the i-gel supraglottic airway. The devices were placed on top of and inside a phantom simulator to resemble the position in vivo. The artefacts with the cLMA, Unique and Supreme were similar and related to ferromagnetic material in the pilot balloon valve. Artefacts were more prominent with the ProSeal. There were no artefacts with the Ambu Disposable Laryngeal Mask or the i-gel.

Insertion and use of the LMA Supreme™ in the prone position*

We investigated whether insertion of an LMA Supreme and its use for maintenance of anaesthesia is feasible in the prone position. Forty adult patients positioned themselves prone and were given propofol until the Bispectral Index was < 50. A size-4 LMA Supreme was inserted by experienced anaesthetists. Ease of insertion, ease of ventilation, efficacy of seal, ease of gastric tube insertion, blood staining, postoperative sore throat, and other complications were recorded. Insertion was successful at the first and second attempt in 37 (92.5%) and 3 (7.5%) patients, respectively. The mean (SD) insertion time was 21 (15) s. Oropharyngeal leak pressure was greater in females than males (29 (4) vs 25 (4) cmH(2)O, respectively, p = 0.01). Adequate ventilation was achieved in all patients. Gastric tube placement was successful in all patients. The frequency of blood staining and sore throat was 7.5% each. No other complications were noted. We conclude that use of the LMA Supreme in the prone position by experienced users is feasible.

Supreme! Or is it?

We would like to congratulate Dr Cook et al. on an excellent study [1]. Having a degree of experience in using LMA Supreme™ (SLMA, Intavent Orthofix, Maidenhead, UK), we would like to add some comments. We use the SMLA for selective patient groups and specific surgery, for example, dacrocystorhinostomy where we use total intravenous anaesthesia and ventilate the lungs via the single-use SMLA. Due to the nature of the surgery there is nasopharyngeal bleeding and blood trickles into the oropharynx. In these cases the perceived advantages of the SLMA are better airway protection from nasopharyngeal bleeding, the achievement of higher airway leak pressure during positive pressure ventilation and the option to pass a gastric tube via the drain tube to aspirate blood from the stomach. After reading Cook et al’s paper, however, we feel that we may need to re-assess our practice. Reasons for this include, firstly, their finding that airway leak pressure was no higher that that achieved with i-gel™ (Intersurgical, Wokingham, UK) in a similar study [2] and does not achieve levels seen with Pro-seal™ LMA (PLMA; Intavent Orthofix, Maidenhead, UK) [3]. Importantly, in the i-gel study only size 4 was used in all patients (weight range 42–113 kg), although no data were presented on how many of these were outside the manufacturer’s recommended weight range of 40–90 kg for this size. In this study the SLMA was sized appropriately and despite this, faired no better than the i-gel. As the study mentioned, the other two clinical studies of the SLMA reported a higher airway leak pressure of 28 cmH2O [4] and 37 cmH2O [5], but both were much smaller studies. Consequently, it seems that the SLMA does not confer any advantages over its direct competitors in this respect. Secondly, it is well recognised that an ideal supraglottic airway device provides access to the glottis so that an tracheal tube, Aintree catheter or a bronchoscope with a loaded tracheal tube could be passed into the trachea. Due to its design the SLMA is unable to achieve this and therefore, in our opinion, this gives its direct competitors an advantage. Moreover, it is fairly rigid and anatomically preformed, which possibly facilitates introduction in normal airways, but in fixed flexed neck deformities where one might use a supraglottic airway device, it may be very difficult or impossible to introduce into the mouth. Again, in our opinion, its direct competitors would fair better in this respect. Finally, the ability to pass a gastric tube into the stomach is a useful feature. The SLMA has this ability, with similar success rates to other devices; however even here it fairs no better than the PLMA as the drain tube only allows the passage of a smaller gastric tube (14 Fr vs 16 Fr), but it is larger than the i-gel allows (drain tube size 12 Fr for size 4). Although it seems reasonable to suggest that the drain tube size could play a major role in preventing aspiration in cases of regurgitation, there are no data to confirm it to date. To conclude, after reading this paper we now think that the SLMA falls in between the PLMA and the i-gel as a choice of supraglottic airway device. Which device should we choose? Perhaps now we would choose to use one or the other over the SLMA in most clinical situations, as there are no proven benefits of it over the other two and at least some theoretical drawbacks. Of course, we are happy to be proved wrong by further research.

LMA Supreme™ Versus Facemask Ventilation Performed by Novices: A Comparative Study in Morbidly Obese Patients Showing Difficult Ventilation Predictors

We designed a study to compare ventilation characteristics performed in morbidly obese patients by medical students via the facemask to that via the LMA Supreme. This prospective, randomized, crossover study included 31 ASA I-III morbidly patients showing difficult mask ventilation predictors. After induction of anesthesia, ten medical students with no previous clinical experience in airway management, clinically educated to facemask ventilation maneuvers, and theoretically educated to laryngeal mask use were supervised by a senior anesthesiologist during performance of 60 s facemask and LMA Supreme ventilation in a randomly assigned order. Ventilation quality and difficulty were measured using an original score calculated as the sum of seven indicators (0=no ventilation and complications, 12=optimal and safe ventilation) and a visual analog scale (VAS; 0=no difficult-100=impossible), respectively. Values are presented as means (standard deviation) or medians [extremes]. Mean age and body mass index of the patients were 39 years (12 years) and 44 kg m(-2) (7 kg m(-2)), respectively. One patient was excluded because of ventilation difficulty experienced by the senior anesthesiologist. Medical students successfully established ventilation with the LMA Supreme in all the 30 patients after a delay of 21 s (9 s) compared to 34 s (14 s) with the facemask (P<0.05). Failure of ventilation occurred in four patients with the facemask. Ventilation quality score was superior and ventilation difficulty (VAS 0-100) was inferior with the LMA Supreme than with the facemask (11 [10-12] and 9 [0-45] versus 5 [1-12] and 50 [5-100]); both P<0.05, respectively. We showed that the LMA Supreme placed in novice hands systematically promoted easier ventilation of better quality than the facemask in morbidly obese patients showing difficult mask ventilation predictors. Our data suggest that the LMA Supreme could be considered as a standard airway management tool for both elective and rescue airway management of morbidly obese patients.

A prospective fiberoptic evaluation of the Supreme™ Laryngeal Mask Airway

Background: Since March 2007, a new disposable Laryngeal Mask Airway has become available. The LMA SupremeTM (LMA-S) aims to combine the LMA Fastrach'sTM feature of easy insertion with the gastric access and high oropharyngeal leak pressures (OLP) of the LMA ProSealTM (PLMA). Methods:We performed an evaluative study with LMA-S size 4 on 100 female patients to measure the ease of insertion, to determine the laryngeal fit by fiberoptic classification, to evaluate the OLP, and to report adverse events. Results: Insertion of the LMA-S was possible in 94 (94.0%) patients during the first attempt and in the remaining five (5.0%) during the second attempt. In one small patient, LMA-S could not be inserted due to limited pharyngeal space. This patient was excluded from further analysis. Insertion of a gastric tube was possible in all patients at the first attempt. Mean time for LMA-S insertion was 12.8 (8-30 ±4.7) seconds. Laryngeal fit evaluated by fiberscopic view was rated as optimal in all patients, both immediately after insertion of the LMA-S and at the end of surgery. After equalization to room pressure, mean cuff volume needed to achieve 60 cmH2O cuff pressure was 18.4 (8-31 ±3.8) mL. Mean OLP at the level of 60 cmH2O cuff pressure was 28.1 (21-35 ±3.8) cmH2O. Eight (8.1%) patients complained of a mild sore throat. No patient reported dysphagia or dysphonia. Conclusions: Clinical evaluation of LMA-S showed easy insertion, optimal laryngeal fit, and low airway morbidity. OLP results were comparable to earlier data from PLMA.