the advantages of the lma over the tracheal tube or facemask: a meta-analysis

7/26/2019 The advantages of the LMA over the tracheal tube or facemask: a meta-analysis

1/7

1017

J B r i m a c o m b e M B C hB F RC A

C l i n i ca l R epor t s

T h e a d v a n t a g e s o f t h e

L M A o v er th e tr a ch e a l

t ube or f acem ask: a

m e t a a n a ly s is

A meta-analysis wasper for me d on randomisedprospective trials

com par ing the l aryngeal m ask a irw ay ( L M A ) w i th o ther f orm s

o f a i rway m anagem en t t o de t e rm ine i f t he L M A o f fe red any

advantages over the tracheal tube (T T) or facem ask (FM). O f

the 858 LM A pu bl icat ions identi fied to D ecem ber 1994, 52

me t th e criteria or the analysis. Thirty-two different issues were

tested using F isher 's m eth od fo r oombining the P values . The

L M A has 13 advan tages over t he T T and fou r over t he F M .

T he L M A had tw o d i sadvan tages over t he T T and one over

the FM . There were 12 issues where nei ther device had a n ad-

vantage. Advantage s over the T T included: increased speed and

ease of plac eme nt by inexperienced personnel; increased spee d

o fplacem ent by anaesthet is ts; improved hae mod ynam ie s tabil ity

at induct ion and during emergence; minimal increase in in-

traocular pressure follo win g insertion; red uced anaesthetic re-

quirements fo r airway tolerance; lower freque ncy o f coughing

during emergence; improved oxygen saturation during emer-

gence; an d lower incidence o f sore throat in adults. Advan tages

over the F M included: easier placem ent by in~x'perienced per-

sormel; improved oxygen saturation; less hand fat igue; a nd im-

pro ved operating conditions dur ing min or paediatric otological

surgery. Disadvantages over th e T T w ere lower seal pressures

and a h igher f r equency o f gast ri c i n su f~ t ion . T he on l y d i s-

advantage comp ared wi th the FM was that oesophageal re f lux

was more l ikely . The importance o f these f indin gs in terms

o f pa t i en t ou t com e cou ld no t be de t e rm ined rom the pub l i shed

data.

Une rr~ta-analyse d'~tudes randomisdes et prospectiw,s com-

para nt le ma sque laryn~ (ML ) avec les autres m ode s de gestion

des voles a~riermes a d ti rdalisde darts le bu t de d~terminer

si le M L prdsentait de s avantages sur le tub e tractu~al (T T)

et le mas que facial (M F~, Des 858 publ icat ions portant sur

le M L compil~es jusqu 'en d~cembre 1994, 52 ont rencontrd les

crit~res de l 'analyse. Trente-deux paru tion s diffdrentes ont dtd

analysdes avec

l

m~thode de F isher pour la combinaison des

valeurs de P . Le M L poss~dai t 13 avantages sur le TT et quatre

sur l e M E L e M L poss~ dai t deux d~ savan tages sur le T T e t

un sur le M E Dan s douze parut ions , au cun des disposi ti fs

n'offrait u n s eul avantage sur les autres dispositi fs. Le s avantages

du M L sur le T T comprenaient: l ' augmentat ion d e la vi tesse

et de la facil it~ d~nsertion pa r du perso nnel inexl~riment~;

l 'augm entation de la vitesse d~nsertion pa r l 'anesttv~siste; I 'am ~

l iorat ion de la s tabi l i t~ h~modynamique d l~nduct ion e t au

r~veil; I 'am~lioration d e la saturation en oxyg~ne ~ la ph ase

de r~ei l ; e t t ree plus faible incidence d e m au x de gorge. Les

avantages sur le M F dtaient: la faci li t~ de mise e n place pa r

le pers onn el inexp~riment~; I 'arr~lioration de la saturation en

oxy g~ e; une f a t i gue m oindre pou r l a m ain ; l' am ~ liora tion de

conditions chirurgicales pe nd an t la chirurgie p dia trique m i-

neure, l_es d~savantages sur le ~ ~taient la baisse de la pression

d~tancheitd e t un e augm entat ion de la f rdque nce d e l nsuf -

f lat ion gastr ique. Le seul d/, savantage sur le M F dtait une plus

grande susceptibili t~ au reflux oesophagien. L~mportance de

ces constatations sur le devenir d u patie nt n'a p u ~tre d~termin~e

partir des donn~es publi~es.

K e y w o r d s

LARYNGEALMASKAIRWAY:meta-analysis r isk benefits.

From the D epartment of An aesthesia, Cairns Base Hospital,

Cairns, A ustralia 4870.

Accepted or publ icat ion 30th June, 1995.

T h e laryngeal m a s k a i r w a y L M A ) h a s g a i n e d w id e -

spr ead accep tance a s a gene r a l pur pose a i r way wi th

wor ldwide usage e s t im a ted a t ove r t en m i l l ion pa t ien t s

by 1993 . l The popu la r i ty o f the dev ice f o r r ou t ine use

s tem s f r om i t s pe rce ived bene f it s fo r the pa t i en t a nd an-

aes the t i s t ove r t r ad i t iona l f o r m s of a i r way m anagem ent .

P r ospec t ive sur veys have shown the ove r a l l succes s r a te

f or the t echn ique to be h igh and the com pl ica t ion r a te

low, 2-5 bu t i t ha s been suggested t hat there is a lac k o f

CAN J AN AE STH 1995 / 42:1 i / pp 1017-23


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1018

C A N A D I A N J O U R N A L O F A N A E S T H E S I A

r a n d o m is e d p r o s p e c t iv e t r i a ls in p e e r r e v ie w jo u r n a l s

d e m o n s t r a t i n g a n y a d v a n t a g e s o v e r t h e f a c e m a s k ( F M )

o r t r a ch e a l t u b e ( I T ) , 6 a v i e w r e i t e r at e d n a recent r e -

v i e w 7 a n d a c c o m p a n y i n g e d i to r i al s p u b l i s h ed i n t h e

Canadian Journal o f Anaesthesia

T h e f o ll o w i n g m e t a - an a l y s is o f r a n d o m i s e d p r o s p e c ti v e

t r ia l s i n p e e r r e v i e w j o u r n a l s w a s p e r f o r m e d t o d e t e r m i n e

i f t h e L M A o f f e r e d a n y a d v a n t a g e s o v e r t h e T I ? o r F M .

M e t h o d s

A l i t e r a tu r e s e a r c h wa s c o n d u c te d to o b ta in a l l p u b l i -

c a ti o n s o n t h e L M A u p t o D e c e m b e r 1 9 94 . T h r e e m e d i c al

d a t a b a s e s (4 8 h o u r s; M e d l i n e a n d R e f e r e n c e M a n a g e r

U p d a t e w e r e s e a r c h e d f o r c i ta t io n s o n t a i n i n g k e y w o r d s ,

s u b j e c t h e a d i n g s a n d t e x t e n t r i e s r e l a t e d t o t h e L M A .

A d d i t i o n a l r e f e r e n c e s w e r e o b t a i n e d f r o m t h e i n d i c e s o f

a n a e s th e t i c j o u r n a l s l i st e d in I n d e x M e d i c u s * a n d a c o m -

p r e h e n si v e b i b l i o g r a p h y p r o v i d e d b y I n t a v e n t , U K . 'f P r o -

s p e e ti v e r a n d o m i s e d s t u d ie s c o m p a r i n g t h e L M A w i t h

th e t r a c h e a l tu b e o r f a c e ma s k we r e s e le c te d f o r a n a ly s i s .

O n l y p a p e r s a n d a b s t r a c ts f r o m p e e r r e v i e w j o u r n a l s w e r e

i n c l u d e d . D a t a f r o m a b s t r a c t s p u b l i s h e d b e f o r e 1 9 9 0 o r

s u b s e q u e n t ly p u b l i s h e d a s a f u l l p a p e r we r e e x c lu d e d .

D a t a w e r e o b t a i n e d f r o m t h e s e l e c te d p a p e r s / a b s t r a c t s

a b o u t t h e t y p e o f c o m p a ra t iv e s t u d y ( L M A v s T T , L M A

v s F M , L M A v s F M v s T I ' ), t h e s tu d y p o p u l at i o n si ze

a n d t y p e ( a d u l t , p a e d i a tr i c o r m i x e d ) , t h e t y p e o f su r g e r y

( p e r ip h e r a l / su p e r f i ci a l o r h e a d / n e c k ) , t h e p h a s e o f a n a e s -

th e s ia s tu d ie d ( in d u c t io n , ma in te n a n c e , e me r g e n c e , p o s t -

o p e r at i v e) , v e n ti l a ti o n m o d e , L M A u s e r ( a n a e st h e t is t o r

n o n - a n a e s th e t i s t ) , s u c c e s s w i th th e d e v ic e ( c o n s id e r e d s u e -

e e ss fu l i f L M A t e c hn i q u e w a s a b a n d o n e d i n < 5 % c a se s )

*Acta Anaesthesiologica Bclgica, Acta Anaesthesiological

Scandinavica, Anaesthesia, Anaesthesia and Intensive Care,

Anasthesiologie und R6anim afion, Anaesthetis t, Anathesiolo-

gie, Intensivmedizin, Noffallm~i~in, Schm erztherapie,

Anesteziologiia I R 6animatologh'a, Anesthesia and Analgesia,

Anesthesiology, Annales Fran~aises D Anesth~sie et de R6ani-

marion, B ritish JournM of Anaesthesia, Cahiers d 'Anesth6-

siologie, Canadian Journ al o f Anaesthesia, Clinical Journal of

Pain, Eu ropean Journ al o f Anaesthesiology, International

Anesthesiology Clinics, Journal of Cardiothoracic and Vascular

Anesthesia, Journ al o f Clinical Anesthesia, Journ al o f Neuro-

s u r g i c al n e s t h e s i o l o g y , l i n i s c h e n a e s t h e s i o l o g i e n d I n t c n -

sivtherapie, Ma Tsui Hsueh Tsa Chi, Japanese Journal of

Anesthesiology, Middle East Jo urnal of Anesthesiology, M i-

nerva Anesthesiologiea, Regional A naesthesie, Regional A nes-

thesia, Resuscitation, Revista Espanola D e A nestesiologia y

R~animacion.

LMA bibliography obtainable from Intavent Research Ltd,

Cedar Court, 9-11 Fairmile, Henley-on-Thames, Oxon RCO

2 J R, U

a n d in s e r t io n t e c h n iq u e s t a n d a r d , 9 o t h e r o r u n k n o w n ) .

A l l i ss u e s a d d re s s e d b y e a c h s t u d y w e r e c a t a l o g u e d a n d

t h e i r P v a l u e s d o c u m e n t e d . T h e c r i t e r ia f o r h o m o g e n e i t y

w e r e t h a t t h e s t u d y i s s u e a n d a n a e s t h e s i a p h a s e w e r e i d e n -

t i c a l . W h e r e t h e s t u d i e s w e r e h o m o g e n o u s t h e P v a l u e s

f o r e a c h i s s ue w e r e p o o l e d a n d a n a l y s ed . A n u l l h y p o t h -

e s is w a s f o rm e d t h a t t h e L M A o f f e re d n o a d v a n t a g e o v e r

t h e I T o r F M f o r a p a r ti c u l a r i s su e . T h i s n u l l h y p o t h e s i s

w a s t e s t e d f o r e a c h i s s u e u si n g F i s h e r ' s m e t h o d f o r c o m -

b in in g th e P v a lu e s . l0 T h e t e s t s ta t i s ti c fo r F i s h e r ' s m e th o d

i s - 2 t i m e s t h e s u m o f t h e n a t u r a l l o g a r it h m s o f t h e

P v a lu e s f r o m e a c h s tu d y , a n d th i s h a s a X2 d i s t r ib u t io n

w i t h d e g r e es o f f r e e d o m e q u a l t o t w i c e th e n u m b e r o f

s tu d ie s . S ig n i f i c a n c e wa s t a k e n a s P < 0 . 0 5 . O n ly i s s u e s

a d d r e s s e d b y t w o o r m o r e t r i a l s w e r e i n c l u d e d i n t h e

me ta - a n a ly s i s . F o r c o n v e n ie n c e , th e s tu d y i s s u e s we r e d i -

v id e d in to s ix s e c t io n s : ( 1 ) p la c e me n t ; ( 2 ) p h y s io lo g y ; (3 )

a i r wa y m e c h a n ic s ; ( 4) a i r wa y p r o b le m s ] c o mp l ic a t io n s ; ( 5)

p o s to p e r a t iv e a s p e c t s a n d ( 6 ) mis c e l l a n e o u s .

Data abstraction

E i g h t h u n d r e d f i ft y -e i g ht p u b l i c a ti o n s o n t h e L M A w e r e

c a t a l o g u e d b y t h e a u t h o r t o t h e e n d o f 1 9 94 . T h i s c o m -

p r i s e d : 1 6 0 p a p e r s , 1 3 2 a b s t r a c t s , 4 0 mi r a - p a p e r s ( l e t t e r s

c o n ta in in g s tu d y d a ta ) , 6 1 f u l l c a s e r e p o r t s , 1 0 5 c a s e r e -

p o r t s a s l e t t e rs to th e e d i to r , 2 8 7 o th e r l e t t e r s , 2 3 r e v ie ws ,

1 5 e d i to r i a l s a n d 3 6 o th e r p u b l i c a t io n s , in c lu d in g c o -

i n c id e n t a l u s e o f t h e L M A i n o t h e r s t u d i e s , ar t ic l e s a n d

m a n u a l s . T h e 1 6 0 c a n d i d a t e p a p e r s a n d 1 3 2 c a n d i d a t e

a b s t r a c t s w e r e e x a m i n e d b y t w o u n b l i n d e d o b s e r v e r s .

W h e r e th e r e wa s a c o n f l i c t in th e o b s e r v a t io n a th i r d

o b s e r v e r w a s u t i l i s e d . T w o h u n d r e d f o r t y p a p e r s / a b -

s t r a c t s f a i l e d to me e t th e c r i t e r i a f o r a n a ly s i s p r ima r i ly

o n t h e g r o u n d s t h a t t h e y w e r e n o t r a n d o m i s e d c o n t r o l l ed

t r i a l s c o m p a r i n g t h e L M A w i t h o t h e r f o r m s o f a i r w a y

m a n a g e m e n t o r h a d n o t b e e n p u b l i s h e d i n p e e r r e v i e w

j o u r n a l s . F i R y - t w o p a p e r s / a b s t r a c t s m e t t h e c r i t e ri a f o r

a n a ly s i s. T h i s in c lu d e d 3 7 p a p e r s n - 4 7 a n d 1 5 a b -

s t r a ct s . 4 s-6 2 T h i r ty - f iv e s tu d ie s c o m p a r e d th e L M A wi th

t h e T F ( re f s. l l - 1 3 , 1 5, 1 7 - 2 3 , 3 1 - 3 5 , 3 7 , 3 8 , 4 0 - 4 7 ,

5 1 , 5 2 , 5 4 - 5 8 , 6 0 , 6 2 ) , 1 4 s t u d i e s c o m p a r e d t h e L M A

wi th th e F M ( r e fs . 1 4 , 1 6 , 2 4 - 2 8 , 3 0 , 3 6 , 3 9 , 4 9 , 5 0 ,

5 3 , 6 1 ), o n e s t u d y c o m p a r e d t h e L M A w i t h t h e T r a n d

F M 4 s a n d t w o s t u d ie s c o m p a r e d t h e L M A w i t h a c o m -

b i n ed T F / F M t ~ h n l q u e w h e re t h e T I w a s r ep l ac e d b y

a F M f o r e m e rg e n c e . 2 9 ~

R e s u l t s

T h e t o t a l s t u d y p o p u l a t i o n w a s 2 4 4 0 p a t i e n t s a n d t h e

m e a n ( S D , r a n g e ) s t u d y p o p u l a t i o n s i z e w a s 4 7 ( 3 0 ,

1 0 - 1 3 0 ). D e t a i l s a b o u t p o p u l a t i o n t y p e , ve n t i la t io n m o d e ,

t h e L M A u s e r, s u c c e ss w i th t h e d e v i c e a n d i n s e rt i o n t e c h -

n i q u e a r e g i v e n i n T a b l e I . T h e m e a n ( r a n g e ) f o r t h e


3/7

B r i m a c o m b e : L M A E V A L UA T IO N 1019

T A B L E I D e t a i l s b o u t p o p u l a t i o n y p e , e n t i la t i o nmode, u s e r ,

s u c c e s s w i t h the d e v i c e a n d i n s er t i on echnique for comparative s t u d i e s

o f t h e l a r yn g e al a s k a i r w a y L M A ) , W a c h c al t ub e C [ T ) a n d o r

f a c e m as k F N 0

L M A / F M L M A / T T L M A / T T / F M T ot al( )

Population type

Ad ult 11 29 1 41 (78.8)

Child 3 6 1 10 (19.2)

Mixed 0 0 1 1 (1 .9)

Ventilation mode

IPPV 3 20 1 24 (46.2)

S V 10 11 2 23 (44.2)

M ixed 1 3 0 4 7 . 7 )

U n k n o w n 0 I 0 I 1 .9 )

User

An aesthe tist 11 31 3 45 (86.6)

Non-anaesthetist 3 4 0 7 (13.5)

Insertion technique

Standard

7

5 0 12 (23.1)

Other 0 0 0 0 (0)

Unkno wn 7 30 3 40 (76.9)

Success rate

< 5 failure 5 15 0 20 (38.5)

>_5 failure 2 5 1 8(15.4)

U n k n o w n 7 1 5 2 2 4 (46.2)

n u m b e r o f i s su e s a s s es s e d b y e a c h p a p e r/ a b s tr a c t a s

4 . 1 I - 1 4 ) . A n u l l h y p o t h e s i s c o u l d b e c o n s t r u c t e d f o r

2 3 i ss ue s b e t w ee n t he L M A a n d T r a n d n i n e b e t w ee n

t he L M A a n d F M . T h e L M A h a d 1 3 a d va n t a g es o v e r

t he T r a n d f o u r o v e r t he F M . T h e L M A h a d t w o di s-

a d v a nt a g e s o v e r t he T r a n d o n e o v e r t he F M . T h e r e

w e r e 1 2 i s s u e s w h e r e n e i t h e r d e v i c e h a d a n a d v a n t a g e .

A d v a n t a g e s o v e r t h e T r i n cl u de d : i n c r ea s e d s p e e d a n d

e a s e o f p l a c e m e n t b y i n c x p e r i en e e d e r s o n n el ; n c r e a se d

s p e e d o f p l a c e m e n t b y a na e st he ti s ts ; m p r o v e d h a e m o -

d y n a m i c s t a b i l i t y

t

i n d u c t i on a n d d u r i n g e m e r g e n c e ;

m i n i m a l r i s e i n i n t r a o c u l a r r e S S U R e f o l l o w i n g n s er t io n ;

r e d u c e d a n a e s th e t i c e q u i r e m e n t s f o r a i r w a y t o l e ra n ce ;

l o w e r f r e q u e n c y f c o u g h i n g d u r i n g em e r g e n c e ; i m p r o v e d

o x y g e n s a t ur a t io n u r i n g e m e r g e n c e ; a n d l o w e r in c i de n c e

o f s o r e t h r o a t i n a du l t s. A d v a n t a g e s o v e r t h e F M i n-

c l u d e d: e a s i er l a e e m e n t b y i n e x p e r ie n c e d e r s o nn e l ; m -

p r o v e d o x y g e n s a tu r a ti o n ; e s s h a n d f a ti g ue ; a n d i m -

p r o v e d o p e r a t i n g c o n d it i o n s d u r i n g m i n o r p a ed ia t ri c

o t ol o gi c al u r g e r y. i s a d v a n t a g e s v e r t h e T T w e r e l o w e r

s e a l p r e s s u r e s a n d a h i g h e r f r e q u e n c y o f g a s t i c n s uf f la -

f i on . T h e o n l y d i s a d v a n ta g e c o m p a r e d w i t h t h e F M w a s

t h a t o e s o p h a g e a l e f lu x w a s m o r e l ik el y. h e d e t a i l e d e -

s u lt s f t h e m e t a - a n a l y s i s r e g i v e n n T a b l e II .

iscussion

Th e r e w e r e a n u m b e r o f de fi c it s in th e a n a ly s e d s tu d ie s

wh ic h l imi t th e f in d in g s . F i r s t ly , o n ly 1 0 /5 2 s tu d ie s we r e

b l i n d e d a l l o w i n g b o t h u s e r a n d o b s e r v e r b i a s . I n m o s t

c h : c u m s ta n c e s th i s w a s n o t a n e r r o r o f s t u d y d e si g n , b u t

r e f l e c t s th e d i ff ic u lt ie s o f b l in d in g o b s e r v a t io n a l s tu d ie s

b e twe e n d i f f e r e n t a i r wa y d e v ic e s . S e c o n d ly , in o n ly 1 2 /

5 2 s t u d i e s w a s a n a t t e m p t m a d e t o d e f i n e t h e L M A i n -

s e r ti o n t e c h n i q ue . I t i s p r o b a b l e t h a t s o m e t e c h n i q u e s m a y

le . u t to s u b o p t im a l p o s i t io n in g a n d th u s in f lu e n c e m e a s -

u r e d v a r i a b le s . 63 F in a l ly , in m o s t s tu d ie s w h i l s t i t w a s

p o s s ib le to d e te r min e i f th e u s e r wa s a n a n a e s th e t i s t , t h e i r

e x p e r i e n c e w i t h t h e L M A w a s u s u a l l y n o t d e f i n e d a n d

t h e r e i s a p r o b a b l e l e a r n i n g c u r v e w i t h L M A u s a g e, c~

De s p i t e th e s e s h o r tc o min g s , th i s a n a ly s i s in d ic a te s th a t

th e r e i s s u b s ta n t i a l e v id e n c e f r o m r a n d o mis e d c o mp a r -

a t iv e st u d i es t h a t t h e L M A h a s s o m e a d v a n t a g e s a n d d i s -

a d v a n t a g e s o v e r t h e t r a c h e a l t u b e a n d f a c e m a s k . U n f o r -

t u n a t e l y t h e d a t a w e r e n o t c o n s i d e r e d t o b e s u f f i c i e n t l y

h o m o g e n o u s t o m a k e m e a n i n g f u l e st i m a t e s o f t h e s iz e

o f t h e d i f f e re n c e b e t w e e n t h e a i r w a y d e v i c e s . T h e r e w a s

a l s o n o e v id e n c e th a t a n y o f th e s e d i f f e r e n c e s r e s u l t in

a n i m p r o v e m e n t i n p a t i e n t o u t c o m e . H o w e v e r , i t is n o -

t o r i o u s ly d i f fi c u lt t o d e m o n s t r a te o u t c o m e b e n e f it s e v e n

w i t h i t e m s o f a n a e s t h e t i c e q u i p m e n t t h a t h a v e b e e n u n i -

v e r s a l ly a c c e p te d s u c h a s th e p u l s e o x ime ter .6 5 ,6 6 F u r th e r -

m o r e , s o m e o f t h e b en e fi ts o f t h e L M A c a n n o t b e m e a s -

u r e d i n r a n d o m i s e d c o n ~ o l l e d s t u d i e s p a r t i c u l a r l y i n

s i tu a t i on s w h e r e t h e L M A c o m p l i m e n t s o t h e r f o r m s o f a i r-

w a y m a n a g e m e n t o r w h e n i t is u s e d i n u n i q u e s i t u a t i o n s

s u c h a s a i r w a y r e s c u e o r a s a n a i d t o i n t u b a t i o n . A l s o ,

w h e r e o n e f o r m o f a i r w a y m a n a g e m e n t i s c o n t ra i n d i c at e d ,

c o m p a r i s o n s b e t w e e n a i r w a y d e v ic e s c a n n o t b e m a d e .

T h e r e a r e s e v e r a l a r e a s w h e r e t h e L M A h a s t h e p o -

t e n t i a l to b e n e f i t p a t i e n t s c o mp a r e d wi th th e TF . T i l e

in c r e a s e d s p e e d a n d r e l i a b i l i ty o f p la c e m e n t b y in e x p e -

r i e n c e d p e r s o n n e l s u g g e s t s a p o te n t i a l r o le in r e s u s c i t a -

l i o n 7 T h e h a e m o d y n a m i c s ta bi li ty t i n d u ct i o n n d d u r -

i n g e m e r g e n c e m a y b e o f b e n e f it t o p a t i e nt s w i t h

c a r d i o v a s c u l a r is e a se , n d a r e c e n t o n t r o l l e d ri al o m -

p a r i n g n o r m o t e u s i v e w i t h h y p e r t e n si v e p a t i e n ts s u p p o r t s

th i s c o n c e p t , c~ Th e min im a l c h a n g e s in in t r a o c u la r p r e s -

s u r e m a y b e o f b e n e f i t t o p a t i e n t s w i t h g l a u c o m a . 37 T h e

l o w fr e q u e n c y o f c o u g h i n g d u r i n g e m e r g e n c e m a y b e b e n -

e f i c i a l t o p a t i e n t s f o l l o w i n g o p e n e y e o r E N T s u r g e r y

wh e r e e x c e s s iv e s t r a in in g i s p o te n t i a l ly h a r mf u l . Th e

L M A m a y e v e n o f f e r a d v a n t a g e s i n t e r m s o f o x y g e n s a t -

u r a t io n d u r in g e me r g e n c e . P o s to p e r a t iv e ly , th e lo w in c i -

d e n c e o f s o r e t h r o a t a n d v o i c e a l t e r a t i o n m a y h a v e a d -

v a n ta g e s f o r p r o f e s s io n a l v o ic e u s e r s a n d r e d u c e o v e r a l l

m o r b i d it y . I t s h o u l d b e n o t e d t h a t t h e a d v a n t a g e s o f t h e

L M A i n t e r m s o f s o r e t h r o a t h a v e n o t b e e n a d e q u a t e l y

d e mo n s t r a te d in c h i ld r e n .


4/7

1 02 0 C A N A D I A N J O U R N A L O F A N A E S T H E S I A

TAB LE II Hypotheses ested for laryngeal mask airway versus tracheal tube (LMA vs T I) and facemask (LMA vs FM) using Fisher 's method

for combining probabil i ty scores. P values that are underlined confer an advantage o the F M or Tr . NS = not s ignificant

u l l l ~ p o t h e s ~

L M A v s T T L M A v s F M

P va/ue ReJ~rences P va/ue Re~ rences

Placement

Ease of placemmt same for non-anaesthetis ts


5/7

Brimacombe: L M

EVALUATION 1021

cidence of aspira t ion is s imilar

t o

t h a t f o r t h e T T a n d

F M du ring elective surgery . 76,77

This m e ta - ana lys i s dem ons t r a te s tha t the LM A ha s s ew

e r a l a d v a n ta g e s o v e r t h e T T a n d F M a n d a f ew di s-

advan tages , bu t does n o t a l low def in it ive conc lu s iom to

be m ade r ega r d ing cho ice o f a i r way . F ur the r r e sea r ch

i s needed

t o

de te r m in e the im por tance o f these advan tages

and d i sadvan tages in t e r m s of pa t ien t ou tco m e and co s t

t o t h e h e a l th c a r e s y s t em a n d t o a ll o w r e c o r n m e n d a t i o m

t o b e m ade . Mal tby has sugges ted

t h a t r a n d o m i s c d c o n

t r o l l e d t r i a l s c o m p a r i n g L M A w i t h t h e T T a n d F M f o r

a r o u t i n e p r o c e d u r e s u ch a s a r t h r o s c o p y w o u l d b e

useful s

However , such s tud ies wi l l r equ i r e m or e m e t icu lous de -

s i g n t h a n a r c d e m o m t m t e d i n m a n y c u r r e n t l y a v a i l a b l e

tr ia ls . In a recent review, Asai and M orr is s ta te that the

t r ue f ea tu r es and r o le o f the LMA wi l l be e s tab l i shed

only th r ough s tud ies in which the dev ice i s used cor -

r ec tly . 7 I t has b een sugges ted tha t a l l au thor s should

desc r ibe the l eve l o f expe r ience o f pe r sonn e l p lac ing the

L M A , t h e m e t h o d o f i n s e rt i o n a n d w h e r e p o s si b le f i-

breo ptic scor ing should be con ducte d. 78,79 Ad ult s tudies

f or r ou t ine p r oce dur es in w hich f i r st t im e inse r t ion r o te s

axe less than 90% , overal l success rotes are less than 9 5%,

or m edian f ib r eop t ic s cor ing i s le s s than 3 . 0 , m ay r e f lec t

subopt im a l use . s

A c i m o w l e d g n m n t s

I would l ike

t o t h a n k

A . B e r r y , D . M e c k l e m a n d C .

M ann f or adv ice wi th the m anusc r ip t .

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the advantages of the lma over the tracheal tube or facemask: a meta-analysis

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