Optimizing LMA ProSeal Insertion in Children: A Randomized Trial Comparing Videolaryngoscopy, Direct Laryngoscopy, and Standard Techniques

Abstract

BACKGROUND: Despite recent advancements, ensuring the successful placement and safe ventilation of second-generation supraglottic airway devices (SAD) remains challenging, particularly in pediatric patients. This study aims to compare three LMA ProSeal insertion techniques to assess their impact on placement effectiveness in children, as measured by oropharyngeal leak pressure (OLP). This study hypothesized that different insertion techniques would have a statistically significant effect on OLP in pediatric patients.<br /> METHODS: This was a prospective, randomized, controlled trial conducted at a single-center university hospital from October 2023 to April 2024. A total of 150 children aged 1-10 years undergoing short surgical procedures (<= 90 minutes) were enrolled. After inserting the LMA ProSeal via standard technique (SD group), direct laryngoscopy (DL group), or videolaryngoscopy (VL group), OLP was measured by detecting air leaks at the thyroid cartilage while closing the valve up to 30 cmH(2)O. A fiberoptic bronchoscope was used to evaluate the glottic view.<br /> RESULTS: Of the 159 screened patients, 150 were analyzed per protocol. OLP was significantly higher in the VL group (median [Q1-Q3], 26 [24.2-27] cmH(2)O) compared to the DL group (23 [21.2-24] cmH(2)O) and SD group (21 [20-22] cmH(2)O) (P<0.001). The DL group showed significantly higher OLP than the SD group (P=0.001). Fiberoptic imaging scores were higher in the VL group than in the other groups (P<0.001). The first-attempt success rate of SAD insertion was comparable between the VL and DL groups (94% each), but lower in the SD group (86%) (p=0.290). The SAD insertion time was significantly longer in the VL and DL groups compared to the SD group (median [Q1-Q3], 21 [19.2-22] s; 21 [19-22] s; 14 [13-16] s respectively, P<0.001), although there was no significant difference between VL and DL. The number of additional maneuvers during SAD placement was similar between the VL and DL groups but lower in the SD group (P=0.008).<br /> CONCLUSIONS: Videolaryngoscopy resulted in the highest OLP and the best fiberoptic views, ensuring superior SAD placement. Direct laryngoscopy improved placement over the standard technique but was less effective than videolaryngoscopy.