comparison of proseal laryngeal mask airway and
TRANSCRIPT
COMPARISON OF PROSEAL LARYNGEAL MASK
AIRWAY AND ENDOTRACHEAL TUBE IN PATIENTS
UNDERGOING LAPAROSCOPIC SURGERIES
Dissertation Submitted in
Partial fulfillment of the University regulations for
MD DEGREE IN ANAESTHESIOLOGY
(BRANCH X)
(REG. NO. 201720753)
MAY 2020
GOVERNMENT THENI MEDICAL COLLEGE
THE TAMIL NADU Dr. M.G.R. MEDICAL UNIVERSITY
THENI
CERTIFICATE
This is to certify that the dissertation titled “COMPARISON OF
PROSEAL LARYNGEAL MASK AIRWAY AND ENDOTRACHEAL
TUBE IN PATIENTS UNDERGOING LAPAROSCOPIC SURGERIES”
is a Bonafide original work done by Dr.K.MAYILVANAN during May 2017 -
May 2020 in partial fulfilment of the requirements for M.D. (Anaesthesiology)
Branch X-Examination of The Tamilnadu Dr.M.G.R. Medical University to be
held in May 2020.
Prof. DR.M.BALASUBRAMANI, Prof. DR.KANNAN BOJARAAJ,
MD., DA., M.D.,D.A.,
Professor and Guide, Professor and HOD,
Department of Anaesthesiology, Department of Anaesthesiology,
Govt Theni Medical College, Govt. Theni Medical College,
Theni. Theni.
Prof. DR.K.RAJENDRAN, M.S., D.Ortho., Dean
Govt. Theni Medical College,
Theni.
DECLARATION
I Dr.K.MAYILVANAN solemnly declare that this dissertation, titled
“COMPARISON OF PROSEAL LARYNGEAL MASK AIRWAY AND
ENDOTRACHEAL TUBE IN PATIENTS UNDERGOING
LAPAROSCOPIC SURGERIES” is a Bonafide record of work done by me
in the Department of Anaesthesiology, Govt. Theni Medical College and
Hospital, Theni under the guidance of Prof. Dr.M.BALASUBRAMANI,
MD., DA., Professor of Anaesthesiology, Govt. Theni Medical College &
Hospital, Theni.
This dissertation is submitted to The Tamilnadu Dr.M.G.R. Medical
University, Chennai in partial fulfilment of the University regulations for the
award of degree of M.D. (Anaesthesiology), Branch X- examination to be held
in MAY- 2020.
Place: Theni Dr.K.MAYILVANAN
Date:
ACKNOWLEDGEMENT
With deep sense of gratitude I thank God almighty for his grace and
close presence, which strengthened and sustained me through this endeavour.
Perfection of work is possible only by the union of master brains,
expertise hands and dedicated hearts of enthusiastic people at the right time.
Thereby it gives mean immense pleasure to thank all the contributors who added
oil to the glowing lamp of my study from the time of its ignition. Their valuable
contributions reflect in the perfection of this study
I wish to express my sincere thanks to Prof. Dr. K.RAJENDRAN,
M.S., D.Ortho, Dean, Govt. Theni Medical College, Theni and the former Dean
Prof. Dr.T. THIRUNAVUKKARASU,M.D.,D.A., for granting me permission
to do my study in this esteemed institution.
I lend this opportunity to express my sincere heart full thanks and
gratitude to Prof. Dr.KANNAN BOJARAAJ,M.D., D.A., Professor and Head
of the Department of Anaesthesiology, Govt. Theni Medical College, Theni for
his motivation, constant supervision and for providing all necessary
arrangements for the conduct of the study, without which this dissertation would
not have materialized.
I would like to place on record my indebtedness to my guide
Prof. Dr.M.BALASUBRAMANI, MD., DA., Dr.M.BALAMURUGAN.,
MD., Professor of Anaesthesiology, Govt. Theni Medical College, Theni for her
constant encouragement, constructive criticism and suggestions throughout the
period of the study.
I express my profound thanks to Prof. Dr. S. VIJAYARAGAVAN,
MD,DA, Prof.Dr.S.VIJAYA,MD., for their wholehearted help and support in
doing this study.
I am extremely thankful to Dr.S.LOGANATHAN, M.D., Assistant
Professor of Anaesthesiology, Govt. Theni Medical College, Theni for his
sagacious advice and appropriate guidance to complete this study.
I thank all the Assistant Professors and Senior Residents of Department
of Anaesthesiology for their keen interest and encouragement during this study.
I thank all the Professors in the Department of Surgery, Orthopaedics,
Obstetrics and Gynaecology, Govt. Theni Medical College, Theni for theirable
help and support during the course of the study.
I also wish to thank all my colleagues for their constant help during this
study. My thanks are due to all the theatre personnel for their willing cooperation
and assistance.
I am deeply grateful to all the patients included in the study, for their
wholehearted co-operation inspite of their illness made this study possible.
I continue to be indebted to all for their support, guidance and care who
directly and indirectly involved in my progress of work and for the successful
completion of this study.
CONTENTS
S. NO CHAPTERS PAGE NO
1 INTRODUCTION 1
2 OBJECTIVES 5
3 REVIEW OF LITERATURE 6
4 MATERIALS AND METHODS 47
5 RESULTS 52
6 DISCUSSION 70
7 SUMMARY 75
8 CONCLUSION 77
9 LIMITATIONS 78
ANNEXURES
ANNEXURE I : BIBLIOGRAPHY
ANNEXURE II: MASTER CHART
ANNEXURE III:PROFORMA
ANNEXURE IV:ETHICAL
COMMITTEE APPROVAL
CERTIFICATE
ANNEXURE V:PLAGIARISM REPORT
ANNEXURE VI:PLAGIARISM REPORT
1
INTRODUCTION
Airway management is the cornerstone of anaesthetic practice, and
virtually every anaesthetic innovation in the past 25 years has had an
impact on some aspect of airway care.(1) The most important foundation of
quality anesthetic practice is safe and effective airway management and the
laryngeal mask airway (LMA) is one of the keystones of modern anesthetic
practice(2). In addition to maintaining a clear patent airway to facilitate the
administration and maintenance of anesthetic agents, it is the role of the
anasthesiologist to ensure adequate maintenance of oxygenation of the
lungs. In the race towards airway maintenance, several devices and
methods with modifications were tried and tested since time immemorial.
However, the search for a quick, safe and a convenient method is still on
and an ideal device or method is yet to be identified.
The endotracheal tube is an amalgam of the ideas and innovations of
physicians across multiple centuries, having gone through multiple
iterations before arriving at its current form.(3) For a very long time, the
gold standard among airway devices has been the endotracheal tube (ETT).
However, considerable morbidities ranging from minor side effects such
as sore throat to more serious complications such as autonomic stimulation
and difficult or failed intubation are seen with laryngoscopy and
endotracheal intubation.(4) Further several hemodynamic changes are seen
2
following endotracheal intubation(5) and to avert this, an increased use of
alternatives like light wand, supraglottic devices and fibre optic scopes
have become a routine in anesthetic practice.
Supraglottic airways (SGAs) offer distinct advantages including an
increased speed and ease of placement, maintenance of haemodynamic
stability during induction and emergence. LMA which is a Supraglottic
device has the advantage of being inserted blindly through the mouth and
into the hypopharynx, forming a seal around the glottic opening allowing
for ventilation.(6)
LMAs are single-use or reusable airway devices which may be used
as an immediate life-saving measure in a difficult or failed airway or as a
method to maintain an open airway during the administration of anesthesia
temporarily as outlined in the difficult airway algorithm published by many
societies of anesthesiology worldwide. Introduced into clinical practice as
early as the 1980s, they were used predominantly in the operating room but
of late have become widely used in the intensive care unit, emergency
department and field settings. In comparison to bag-valve mask, LMAs
are easier to use and more effective especially in the hands of basic life
support providers and may be used as an alternative to intubation by
advanced life support providers. A safe and effective method of securing
an airway in anesthesia and critical care settings is provided by LMA. For
these reasons, the Australian resuscitation council and The American
3
Society of Anaesthesiologists have endorsed the LMA as rescue airway,
and as a first line airway management device in those with limited airway
management experience.(7)
The classical laryngeal mask airway (cLMA), first described in
1983, fills the gap between the face mask and tracheal tube by achieving
precise anatomical position and greater degree of invasiveness. It has
gained widespread acceptance as a general-purpose airway for routine
anaesthesia, and with the development of the reinforced LMA, a number
of specialized uses have emerged. The safety and efficacy of the device for
spontaneous and controlled ventilation during routine use has been
confirmed by published data from large studies.(8) The hemodynamic
response following insertion of Laryngeal Mask Airway (LMA) is
considerably less when compared to laryngoscopy.
Several modifications, additions, and variations of LMA have been
developed and are currently in use despite the classic LMA providing an
airtight seal over the glottic opening to provide effective gas exchange.(9)
Designed and introduced in 2000 by Dr. Archie Brain, the ProSeal™
laryngeal mask airway (PLMA; Intavent Orthofix, Maidenhead, UK), is
based on the classic laryngeal mask airway (cLMA).(10) Several
modifications were designed to enable separation of the gastrointestinal
and respiratory tracts, diagnose mask misplacement, enable controlled
ventilation and improve the airway seal. A drain tube (DT) aims to reduce
4
risks of gastric inflation, regurgitation and aspiration of gastric contents
and also enables diagnosis of mask misplacement.(11)
A randomized controlled study would be ideal to identify the various
hemodynamic changes associated with ETT and Proseal LMA. With the
aforesaid background information this study is intended to study the
various advantages of Proseal Laryngeal Mask Airway as opposed to Endo
Tracheal Intubation for subjects undergoing general anesthesia for various
laparoscopic surgical procedures in a Tertiary Care Setting.
5
OBJECTIVES
1. To compare the Hemodynamic parameters during Proseal LMA
insertion with ETT insertion
2. To compare the ease of Proseal LMA insertion with ETT based
on number of attempts, duration of insertion
3. To compare the ease of Ryle’s tube insertion while using
PLMA and ETT based on attempts at insertion and timing of
insertion
4. To find out the incidence of post-operative side effects
assocuiated while using PLMA and ETT
6
REVIEW OF LITERATURE
Anaesthesiology a branch of medical sciences has a wide scope of
services which ranges from perioperative patient care to critical care,
trauma care, pain management and palliative care. Anaesthesiology has
developed into a major speciality. In the last 150 years and its rate of
advance has seen tremendous shifts comparing to most other branches of
medicine. There has been increased understanding of drug delivery,
physiology and monitoring. It has made even the most difficult surgical
and diagnostic procedures possible to undertake, which were considered
impossible earlier Anaesthesiologists play a predominant role during
surgery by maintaining the anaesthetic state of the patient during surgery
and help in recovering from anaesthesia after surgery.(12) Providing good
anaesthesia is like an art, which is better practiced than learnt and is
enjoyed by the patients from the time of their induction to recovery. With
the invent of anaesthesiology, the complicated surgeries and diagnostic
procedures have become an easy task. Anaesthesiology has become special
advanced branch of medicine, which includes labour analgesia, patient
controlled analgesia, Bispectral Index (BIS) monitors, fibre optics,
simulators and robotic surgeries.(13)
7
It is estimated that each year in the United States nearly 40 million
anesthetics are administered for surgical and other procedures. More than
90 percent of these anesthetics involve Anesthesiologists. In the operating
room, anaesthesiologists are responsible for the medical management and
anesthetic care of the patient throughout the duration of the surgery. The
anesthesiologist must carefully match the anesthetic needs of each patient
to that patient’s medical condition, responses to anesthesia and the
requirements of the surgery.(14)
As anaesthesiologists are entrusted with patient safety during
administration of anaesthetic agents during general anesthesia,
management of airway becomes a prime importance to the
anesthesiologist. Since time immemorial several devices have been tried
for airway maintenance and delivery of anesthetic agents. The discovery
of endotracheal intubation was the most important milestone in the field of
anaesthesia and it is usually done by using direct laryngoscopy under direct
vision.(15) However, it has disadvantages of triggering hemodynamic
changes and reflexes which can at times be dangerous to selected groups
of patients.(16,17)
Anaesthesia units dispense a mixture of gases and vapors and vary
the proportions to control a patient’s level of consciousness and/or
analgesia during surgical procedures. An anesthesia system comprises
platform for delivery of gas, a system for distribution including analysis,
8
and several monitors which are optional in most units. Several
cardiopulmonary function and/or gas and agent concentrations in breathed-
gas mixtures are indicated by levels and variations of several physiologic
variables.
UPPER AIRWAYS – Structure and Function(18)
Anatomically the passage through which the air passes in and out of
lungs during respiration is called airway which may be divided into upper
and lower airway.
The upper airway comprises of
Nasal cavity
Oral cavity
Nasopharynx
Oropharynx
Pharynx
Larynx.
The lower airway comprises of
Trachea
Bronchi
Bronchioles
Alveoli
9
Figure 1 : ORAL CAVITY
MOUTH:
It extends from mouth opening bounded by the upper and lower lips
up to anterior tonsillar pillars. Cheeks are made up of muscles, buccal pad
of fat and the parotid gland. The floor of mouth has soft tissue, muscles,
tongue and has opening of submandibular glands. The mouth cavity is
formed by maxilla, mandible and teeth in front, above by hard palate and
soft palate, below by anterior 2/3 of tongue. An ability to maintain good
mouth opening is more important for effective airway management.
10
Figure 2 : EXTERNAL NOSE
NOSTRILS:
It has a free tip and a root at its junction with the forehead. The lateral
margins of the nostril are called alae nasi. The framework of the nose is
formed by bones and cartilages. The upper part is supported by a pair of
nasal bones, frontal process of maxillary bone and nasal part of frontal bone
and the lower part is formed by upper and lower nasal cartilages with
contributions from septal cartilages. In estimating the length of airway
devices, the distances from alae nasi to various points on the external ears
are used.
11
Figure 3 : LATERAL VIEW OF NASAL, ORAL PHARYNX AND
LARYNX
NASAL CAVITY:
The inside of the nasal cavity presents an irregular surface and is
usually triangular in cross section. The nasal septum which is made up of
bony and cartilaginous parts separates the nasal cavity into right and left
halves. The nasal cavity which is the narrowest part of the upper airway,
extends from anterior nares to nasopharynx posteriorly. The roof of the
cavity is formed by the cribriform plate of ethmoid and the floor by the
palatine process of maxilla and palatine bone. The lateral wall is irregular
12
due to presence of 3 turbinates and it houses the openings of paranasal
sinuses. The important function of the nasal cavity is warming and
humidification of air as it passes through the nose.
PHARYNX:
The pharynx is a fibro muscular structure which extends from the
base of the skull up to the level of the 6th cervical vertebra or cricoid
cartilage. It becomes continuous with the oesophagus and larynx.
The pharynx is divided into
Nasopharynx
Oropharynx
Laryngopharynx
NASOPHARYNX:
It is a continuation of the nasal cavity and extends from the base of
skull to the soft and hard palate below. It communicates with nasopharynx
through the posterior nares or choana. It consists of the nasal cavity,
septum, posterior end of turbinates, adenoids and the eustachian tube
openings. It bounded posteriorly by the body of C1 and C2 vertebrae.
OROPHARYNX:
Oropharynx extends from hard and soft palate above to hyoid bone
below and is bounded below by the base of tongue up to the epiglottis. It
13
includes the tonsils, uvula and epiglottis. The vallecula is the space
between epiglottis and the base of the tongue and has paired depressions
on two sides of the median glossoepiglottic fold. The tip of laryngoscope
blade lies in vallecula during classical laryngoscopy. The elevation of
larynx upward produced by pressure using laryngoscopy blade helps to
align the pharyngeal and laryngeal axes thereby enabling direct
visualization of the laryngeal inlet.
LARYNX:
It extends from the laryngeal inlet to the lower border of cricoid
cartilage. It protects the lower airway as an inlet valve from the contents of
the Gastro Intestinal Tract during the act of deglutition and also acts as an
organ of voice. It lies at level of C3 to C6 body of vertebrae. It moves
vertically and anteroposteriorly during swallowing and phonation. Larynx
includes cartilages which are paired and unpaired. Three unpaired
cartilages include the thyroid, cricoid, and epiglottis while the paired
cartilages include the arytenoids, corniculates and cuneiforms.
14
Figure 4 : LARYNGEAL CARTILAGES
The epiglottis is leaf like cartilage which has a broad free upper
margin. Its lower end is attached to the angle between the inner aspects of
laminae of the thyroid cartilage. The epiglottis is connected to the base of
the tongue by a median glossoepiglottic fold and 2 lateral glossoepiglottic
folds.
The thyroid cartilage is the largest of the laryngeal cartilages. It is
shaped like a “v” and is made up of 2 quadrilateral laminae. In male, the
line of junction formed by 2 laminae is acute and it raises a projection on
the outside called ‘Adams apple’. Vocal cords are attached to the inner
aspect of the laminae of thyroid cartilage.
15
The cricoid is the laryngeal cartilage which forms a complete ring
and resembles a signet shaped ring. The cricoid forms the narrowest part
of the airway especially in children placing it at a high risk for impaction
of foreign bodies. A membrane which extends from cricoid cartilage to the
thyroid cartilage anteriorly is known as the cricothyroid ligament. The
upper free border of this conus elasticus membrane forms the vocal cord.
Arytenoids are pyramidal shaped paired cartilages. The apex of the
arytenoids articulates with corniculate and cuneiform cartilage. Vocal cord
are attached to the vocal process of the arytenoids cartilage and movements
of these cartilages are responsible for adduction and abduction of vocal
cords. Corniculates lies at the apex of arytenoids. Cuneiforms are rods
shaped and it is situated in front of corniculate.
16
Figure 5 : LARYNGEAL CARTILAGES
Figure 6 : VOCAL CORD
17
History of Endotracheal Intubation
In the beginning, there were only blind or tactile techniques like
indirect laryngoscopy to visualize the larynx. The Spanish singing
instructor Manuel Garcia (1805-1868) introduced this concept through his
paper titled “Observations on the Human Voice,” wherein he described the
visualization of active vocal cords during vocalization. He managed to
view the vocal cords by placing small mirrors at the end of instruments that
provided specific angles.(19)
The first to perform an endotracheal intubation was probably the
eminent Belgian anatomist, Andreas Vesalius in 1543 (Vesalius, 1543).
Andrea Vesalius is to be regarded as the inceptor of endotracheal
anaesthesia, even though the full significance of his classical experiment
did not become apparent for many years. He inserted a tube of reed or cane
into the trachea after performing a preliminary tracheostomy on a pig,
opened the thorax and then applied artificial ventilation by blowing down
the tube. One of the most advanced and skillful manoeuvre, its value as a
means of maintaining pulmonary ventilation after thoracotomy was fully
appreciated only centuries later(20)
The person credited with the first description of anesthesia
administered via an endotracheal tube is William Macewen, a surgeon in
Glasgow Glasgow following his idea of removing a malignant tumour from
base of tongue of a patient. Macewen realized the importance of
18
endotracheal tubes to protect the airway from blood and surgical debris
which was accomplished by placing a pharyngeal pack around the tube
instead of an inflatable cuff for oral and upper airway surgery.(21) In
addition, he noted as the surgeon and anesthetist did not compete for access
to the mouth and airway, he noted the additional benefit of uninterrupted
surgery that endotracheal anesthesia allowed. He preferred the nasal route
for intubation using metal tubes.
Figure 7 : Pugh’s air pipe
However, performing endotracheal intubations did not become
common practice until blind nasotracheal intubations was introduced
during the First World War by Dr Ivan Magill. Today, endotracheal
intubations have become routine in the anesthesia and critical care settings.
Indeed, an ETT is the most effective and safe method of securing an
airway. Benjamin Pugh, a Chelmsford surgeon performed endotracheal
intubation for resuscitation, in 1754, by using an "air pipe" (fig. 7) made
from a coiled wire covered with soft leather. A tactile technique was used
19
to insert the "air pipe" orally into the trachea of an asphyxiated neonate.
The anesthesiologist then blew down the tube intermittently. Although the
introduction of the pipe was difficult and usually traumatic, it proved to be
an effective method. (20,22)
Endotracheal intubation is known to induce several hemodynamic
changes like reflex cardiovascular responses such as increase in heart rate,
arrhythmias, increase in blood pressure, myocardial ischemia, infarction
besides hypoxia, hypercapnia, bronchospasm, laryngospasm and rarely
causes rise in intracranial pressure and intraocular pressure.(23–25)
However, the realization that other less invasive devices can be used
in a wide number of situations prompted a search for a suitable alternative.
For the device to be less invasive at the same time being able to make gas
exchange effective by providing an airtight seal, it should be supraglottic
in nature.(22) The most important and widely used supraglottic device today
is the laryngeal mask airway (LMA)(9)
20
Table 1: CLASSIFICATION OF SUPRAGLOTTIC DEVICES(26-28)
First generation devices Second generation devices
Simple airway tubes Airway tubes with addition of drainage
tubes
Classical Laryngeal Mask
Airway (cLMA)
Flexible LMA
Unique LMA
Cobra Perilaryngeal LMA
Proseal LMA
I-GEL, Laryngeal Tube
LMA Supreme
Streamlined Liner of the Pharyngeal
Airway
1. The Laryngeal Mask Airway Family
LMA Classic
LMA Unique
LMA Flexible
LMA Fastrach
LMA Ctrach
LMA Proseal
2. Other supraglottic airways similar to Laryngeal Mask
Soft Seal Laryngeal Mask
Ambu Laryngeal Mask
Intubating Laryngeal Airway
21
3. Other supraglottic airway devices
Laryngeal Tube Airway
Perilaryngeal Airway
Streamlined Pharynx Airway Liner
BASED ON GENERATION
Table 2: Features of first and second generation supraglottic devices
First Generation Second Generation
Simple airway
Low pressure pharyngeal seal
May or may not protect from
aspiration
Have no specific design to
lessen the risk
Examples
CLMA
Flexible LMA
Laryngeal Tube
Cobra Perilaryngeal Airway
Specially designed for safety
High pressure pharyngeal seal
Reduce the risk of aspiration
May be more efficacious in
ventilation
Examples
PLMA
Supreme LMA
Gel
SLIPA
22
BASED SEALING MECHANISM
Table 3: Classification of supraglottic devices based on sealing
mechanism
Cuffed peri-laryngeal
sealer
Cuffed pharyngeal
sealer
Cuff-less preshaped
sealer
Non directional non
esophageal sealers -
CLMA, Flexible
LMA, Unique LMA
Directional non-
esophageal sealing -
Fastrach
LMA,ALMA.
Directional esophageal
sealing -
PROSEAL,Supreme
LMA.
Without
esophageal sealing
-COPA,PAX
With esophageal
sealing -
Combitube,
LT,LTS
With esophageal
sealing – BASKA,
I –Gel,
Without
esophageal sealing
- SLIPA, AIRQ
23
BASED ON NO OF LUMEN
Single lumen devices - CLMA, Flexible, Unique, ILMA, Ambu,
Cobra, SLIPA, Laryngeal Tube
Double lumen devices - Proseal LMA, Combitube, Airway
Management Device
Triple lumen devices - Elisha Airway Device
FEATURES OF AN IDEAL SAD:
During both spontaneous and positive pressure ventilation, an
efficient seal of the upper airway is a must
There should be low resistance to gas flow
Should protect airway from upper airway secretions and contents of
GIT
SUPRA GLOTTIC AIRWAYS
1st Generation
Airway tube only
Additional design features to reduce the
risk of aspiration
2nd Generation
Higher seal pressures to enable controlled
ventillation at higher airway pressure
Integral bite block to protect the patients
airway against occlusion
24
The incidence of airway morbidity and adverse events should be low
It should be easily accepted by the oropharynx in terms of shape,
material, cuff volume and cuff position
Basic design and features of Laryngeal Mask airway
In the operative setting in pre-selected patients on fasting, LMAs
may be used as a primary airway management device. LMAs are used as a
temporary bridge to intubation especially by pre-hospital providers in the
emergency setting, in cardiac arrest situations, as a rescue device in
difficult airway situations and in a failed airway situation as a means to
attempt ventilation followed by either intubation through the device or
while a surgical airway is performed.(5,29,30)
Though LMAs are excellent alternatives when compared to bag
masks in reducing the risk of gastric inflation thereby decreasing the risk
of aspiration, they are far less protective than an endotracheal tube. LMAs
are an effective method of ventilation and should be utilized unless it is
ineffective in patients requiring prolonged mask ventilation.LMAs have
been used successfully in pediatric patients, adults, and the obese.
In the development of airway devices over the past 20 years, LMA
is the most important. It is designed for airway management of cases with
spontaneous ventilation and has been listed in five different places in the
25
ASA difficult airway algorithm as an airway or a conduit for ETT
intubation.
Dr Archie Brain, an anesthesiologist from the United Kingdom is
the inventor of the LMA. Though the development on the LMA started as
early as 1981, it was available for commercial use, in the United States
only by 1992. Since its introduction, several modifications, additions, and
variations have been developed, and are currently in use(9).
Types of LMA
Classic LMA
Figure 8 : Classical Laryngeal Mask Airway
The classic LMA consists of a flexible tube called airway tube which
is provided with 15 mm male adaptor and with an inflatable mask. The
mask is a flattened, pearshaped with an open front. The mask is bordered
26
by an oval, inflatable, cuff made up of silicone is designed to seal around
the laryngeal inlet. If properly positioned, the opening overlies the glottis
and the proximal end opposes the base of the tongue and the distal rim
wedges against the upper esophageal sphincter, making a seal. The classic
LMA is autoclavable and reusable. There are two plastic bars at distal
opening of the cuff called aperture bars whose role is to prevent obstruction
by epiglottis. An inflation tube and self-sealing pilot balloon are present at
the proximal end of the tube. LMA is sterilized by stream autoclaving and
is reusable 40 times. The intracuff pressure recommended for LMA
maximum level is less than 60 mm H2O which is the perfusion pressure of
the pharyngeal mucosa. Pressures above this level produce is known to
produce pharyngeal mucosal injury and increase the incidence of sore
throat.
Proseal LMA
The ProSeal LMA is a modified version of the classic LMA and was
released in the year 2000. The distal tip has an esophageal drainage port
designed to communicate with the gastrointestinal tract In addition to the
silicone rim intended to obtain a seal around the larynx,. The port permits
suctioning, potentially decreasing the risk of gastric content aspiration(10).
The LMA is available currently in eight sizes(28)
27
Table 4: Various sizes of LMA
LMA size Weight of patient
Maximum cuff
inflation volume
(mL)
1
1.5
2
2.5
3
4
5
6
Neonates/infants upto 5 kg
Infant between 5 and 10 kg
Infants / children between 10 and 20 kg
Children between 20 and 30 kg
Children 30 to 50 kg
Adults 50 to 70 kg
Adults 70 to 100 kg
Adult over 100 kg
4
7
10
14
20
30
40
50
ADVANTAGES OF LMA:
Lower hemodynamic instability due to less stimulation of sympathetic
system
Avoidance of laryngoscopy and muscle relaxants
The patient tolerates it even under light plane of anaesthesia
Ease of insertion and smooth recovery
Used as a life saving device in securing airway in cases of “cannot
ventilate, cannot intubate situations”
Displacement of bacterial colonies from oral or nasal to lower
respiratory tract is minimal
Lesser chances of injury to airway compared to ETT
Pollution to operating room is less compared to face mask.
Recovery and emergence time is less
28
DISADVANTAGES AND CONTRINDICATION OF LMA:
It is not a definite airway
It does not provide protection against aspiration so contraindicated in
full stomach patient
Not useful in patient with glottis and supraglottic obstruction, or
pathology
Not recommended for patients with poor lung compliance as it needs
high inflation pressure
Patients with restricted mouth opening
Oral and cervical pathologies like large goitre, tumour.
INDICATIONS OF LMA: (31,32)
Elective surgeries like short elective surgical procedure as an alternative
to ETT intubation.
Anticipated and unanticipated difficult airway
In situation like cannot ventilate and cannot intubate
In cardiac arrest – during CPR as an alternative to ETT intubation
Used as conduit for ETT insertion when difficult intubation occur
Useful in radiation therapy, diagnostic and interventional radiology,
ECT, endoscopy
As a bridge to extubation
29
Ophthalmic, neurosurgery, unstable cervical spine, supplementing
regional block – useful in above procedures
COMPLICATION OF LMA:
Aspiration of gastric contents
Gastric distension
Complete or partial airway obstruction
Traumatic injuries to the tongue, soft palate, uvula, tonsils, epiglottis
and pharyngeal mucosa.
Dislodgement occurs accidentally when not in proper position, cuff is
overinflated or inappropriate size is used
Damage to LMA, failure to inflate or deflate can occur
Bronchospasm, dysphagia and nerve injury may occur during LMA
use
PROSEAL LMA(26)
Proseal Laryngeal mask airway was developed and introduced by
Dr. Archie brain in year of 2000. It was developed in order to prevent
aspiration and for effective positive pressure ventilation.
DESCRIPTION OF PROSEAL LMA:
It has following parts mask, airway tube, pilot balloon with inflation
line, drain tube. It is made up of silicone and is reusable. All components
are latex free. There are 6 sizes available now.
30
Table 5: Features of various sizes of proseal LMA
LMA Proseal
LMA
Size
Patient
weight
(Kg)
Maximum
cuff
inflation
volume
(ml)
Maximum
gastric
tube size
(French)
Maximum
fiberoptic
scope size
(mm)
Length
of drain
tube
(cm)
Largest
tracheal tube
(ID in mm)
1.5
2
2.5
3
4
5
5 – 10
10 – 20
20 –30
30 – 50
50 – 70
70 - 100
7
10
14
20
30
40
10
10
14
16
16
18
-
-
-
-
4
5
18.2
19.0
23.0
26.5
27.5
28.5
4.0 uncuffed
4.0 uncuffed
4.5 uncuffed
5.0 uncuffed
5.0 uncuffed
6.0 cuffed
Table 6: Maximum cuff dimensions of proseal LMA
Maximum cuff dimensions(33)
Mask size Air
volume
Maximum
bulge of
cuff
tip (mm)
Maximum
bulge of
wide end of
cuff (mm)
Maximum
transverse
diameter of
cuff (mm)
1
1.5
2
2.5
3
4
5
6
10
15
21
30
45
60
7.8
9.5
11.5
13.0
14.8
17.0
21.1
8.6
10.2
13.0
14.5
16.6
19.0
22.4
26.3
32.6
39.0
45.0
51.2
58.5
68.3
31
The cuff is intended to fit to the anatomy of the perilaryngeal
structures, with its lumen in front of the laryngeal opening. It has a large
ventral cuff that is attached to a second rear cuff which is attached to the
dorsal surface of the mask. This rear cuff helps to improve seal around
periglottic tissue. This rear cuff arrangement makes the proseal LMA
withstand higher seal pressure of 35 cm H2O. Airway tube is short and
smaller than classic LMA. The airway tube is reinforced with wire which
makes it flexible and prevents collapse. Its end is connected to a 15 mm
connector. Distal end of tube has an insertion slot for the introducer tool.
The PLMA bowl is deeper and does not have aperture bars. The
drainage tube traverses the cuff to open distally which is parallel and lateral
to airway tube. This facilitates passing gastric tube, Doppler probe,
thermometer and stethoscope into the oesophagus. This tube is intended to
divert regurgitated fluids and prevent gastric insufflations.
The position of the tube within the bowl is designed in such a way
to prevent the epiglottis occluding the airway tube, as a result of which the
aperture bar is not required. This reduces the resistance to gas flow. The
double tube design has an important role to provide greater stability to the
device after insertion. To protect the tube against the patient from biting, a
built in bite block is present in proximal end of the tubes. It prevents
obstruction to airway tube and also provides information about depth of
insertion. It helps to fuse airway and drainage tube together.
32
A malleable reusable introducer is available in order to facilitate
placement of proseal LMA. It is a curved blade with guiding handle. The
distal end fits into introducer strap and the proximal end clips into the
tubes. PLMA is reusable up to forty times. This should be discarded if it
fails the pre check test. A rectangular depression of the proximal bowel
tube act as an accessory ventilation port and prevents pooling of secretions
at distal airway opening.
PRE – PLACEMENT TEST:
Visual inspection:
Examine the transparency of the airway tube. A discoloured tube
impairs the ability to see foreign particles or regurgitated fluids. Examine
the device for any external or internal damage. Flex the tube up to but not
beyond 180 degree at the junction of the LMA cuff to the shaft. The tube
is not to be used if it kinks at this degree.
Inflation and deflation:
The cuff is fully deflated with syringe so that its wall approximates
against each other. Discard the device if it re-inflates. Next, inflate the cuff
with air and see for any air leakages or any irregular shape. If any changes
are present discard the device.
33
Care and cleaning: (34,35)
The PLMA is washed in warm water and an 8-10 % dilute sodium
bicarbonate solution. Thoroughly wash the PLMA in tap water to clean
airway tube, drainage tube and cuff. The inflation valve fails if cleaning
solution enters into the valve. Care should be taken to prevent damage to
the valve.
The PLMA is sterilized by steam autoclaving method. Before
autoclaving the cuff should be fully deflated. Remove all water from the
cuff before autoclaving. Temperature used for autoclaving is up to 135
degree Celsius. After sterilization the device should be allowed to cool to
room temperature before use.
Figure 9 : LMA INSERTION:(17)
34
Figure 10 : PROSEAL LMA AND ITS PARTS
Figure 11: Patient end of LMA
Proseal. The drain continues to an
opening in the tip
Figure 12 : The dorsal aspect of
the cuff of Proseal LMA
35
Figure 13: PROSEAL LMA RADIOGRAPH
Figure 14 : PROSEAL LMA POSITION
36
Figure 15 : PROSEAL LMA DIFFERENT SIZES
Figure 16 : PROSEAL LMA INTRODUCER
37
INSERTION METHODS:(36–38)
Index finger insertion technique
Finger insertion technique is not recommended for proseal LMA sizes
1½ -2½. These sizes have a dedicated introducer
Hold the proseal LMA like a pen with the index finger pushed into
the introducer step
Under direct vision, press tip of the cuff upwards against the hard
palate and flatten the cuff against it. As the index finger passes further
into the mouth, finger joint begins to extend.
The jaws should not be held widely open.
Push the jaw downwards with middle finger or instruct the assistant
to pull lower jaw downwards momentarily using the index finger to
guide the device, press downwards towards the other hand, exerting
counter pressure
Advance the device into hypopharynx until a definite resistance is
felt. Full insertion is not possible unless the index finger is fully
extended and wrist is fully flexed.
The non-dominant hand is always brought from behind the head of the
patient in order to press down on the airway tube before removing the
finger.
38
This prevents the device from being pulled out of place when the finger
is removed and also permits completion of insertion if this has not been
achieved by the index finger alone. At this point the proseal LMA
should be correctly located with its tip firmly pressed up against the
upper oesophageal sphincter. Remove the finger.
DEVICE INFLATION:
Following insertion, the direction from which the tubes emerge
from the mouth is caudal. Without holding the tubes, inflate the cuff with
just enough air to obtain an intracuff pressure equivalent to approximately
60 cmH2O. Do not hold the tube during cuff inflation as this prevents the
mask from settling into its correct location. Never over inflate the cuff.
The following are the signs of correct placement may include one or
more of:
Slight outward movement of tube upon inflation
Presence of smooth oval swelling in the neck around the thyroid
and cricoid area
DEVICE FIXATION:
Once inflated, the device should be fixed in place with fish mouth
taping (maxilla to maxilla). While fixing, ensure that the tip of the mask
is pressed securely against the upper oesophageal sphincter. Correct
fixation is more critical for PLMA because any migration proximally of
the tip from hypopharynx will result in air leakage up the DT during IPPV.
39
PROBLEMS WITH PLMA PLACEMENT & APPROPRIATE
CORRECTIVE MANEUVERS
An inadequate depth of anaesthesia may result in coughing and breath
holding during insertion. Should this occur, anaesthesia should be
deepened immediately.
If the patient’s mouth cannot be opened sufficiently to insert the
mask, first ensure that the patient is adequately anaesthetized, the
help of an assistant may be needed to pull the jaw- downward.
The cuff must press against the palate throughout the insertion
maneuver; otherwise the tip may fold back on itself or impact on an
irregularity or swelling in the posterior pharynx (eq. Hypertrophied
tonsil). It is necessary to withdraw the mask and reinsert it if the cuff
fails to flatten or begins to curl over as it is advanced.
TESTS FOR PLACEMENT:(4)
1. Depth of insertion:(39)
It has been observed that when most of the bite block was outside
the patient’s mouth, PLMA was frequently malpositioned. For women,
mean depth of insertion has been found to be 18.6cm and for men
20.9cm.
40
2. Test for Obstructed Airway:
The rise and fall of the chest and square wave capnograph and
normal compliance of reservoir bag following manual ventilation
indicates unobstructed placement of PLMA.
3. Soap Bubble Test:(40)
Figure : 17 Soap Bubble Test
This is done to evaluate the seal with GIT. Non-toxic soap solution
is used to create a membrane over DT tip and dislodgement of membrane
happens following leak during IPPV.
Uses:
Confirms PLMA location behind cricoids cartilage.
Zero leak at PLMA Oesophageal junction is confirmed
With spontaneous ventilation it detects negative DT pressure
and aerophagia
Diagnoses oesophageal insufflation during IPPV.
41
4. Lubricant Jelly Test:
It evaluates seal with GIT. About 0.5 to 1 ml of lubricant jelly is
placed in the proximal end of the DT to seal it. If there is a leak from the
DT, the bolus of jelly is blown off.
5. Suprasternal notch tap test:(41)
This is used to determine whether the leading edge of PLMA lies
behind the cricoid cartilage. A non-toxic soap solution is placed across
the proximal end of DT creating a membrane. The suprasternal notch is
the gently tapped. A pulsating soap membrane with tapping confirms the
tip location behind cricoid cartilage.
6. Gastric Tube placement test:
When there is no leak up the DT, then insertion of gastric tube is
attempted via DT without using much force. This gives information
about the DT patency which is mandatory for safe use of PLMA.
OROGASTRIC TUBE INSERTION:(42)
The primary function of the draintube is to provide a separate
conduit from and to be alimentary tract. This is then passed down the DT
of PLMA without any haste or force. A slight resistance is normal felt as
the tip passes against upper oesophageal sphincter. There is an inherent
resistance to gastric tube insertion after 23cm of passage due to
42
angulation of nine degrees in the passage of DT to its tip. There may be
difficulty in passing gastric tube due to following reasons.
1. Selection of too large gastric tube
2. Inadequate lubrication
3. Use of cooled gastric tube
4. Cuff over inflation
5. Malposition of PLMA
The advantages of inserting gastric tube are
1. It allows removal of gas or fluid from the stomach
2. Confirm position/Patency of drainage tube
3. Functions as a guide to PLMA insertion if accidental
displacement occurs.
The disadvantages of inserting gastric tube are
1. Risk of tracheal placement
2. Oesophageal perforation rarely
3. The presence of gastric tube may trigger regurgitation by
interfering with oesophageal sphincter function.
4. Gastric tube blocks drainage tube so that gas and fluid can
not escape from oesophagus.
43
TEST FOR DT AIR LEAK AND PATENCY
Airleak
Large volume leaks are detected by listening over drainage tube or
feeling the air with hand. Small volume air leaks are detected best by
placing water-based lubricant or soap bubble over the end of drain tube.
TESTS FOR PATENCY
1. Passage of gastric tube
2. Passage of fibreopticscope(33)
3. Supra sternal notch tap test.
OTHER INSERTION TECHNIQUES:
Introducer method
Guided method
Thumb insertion method
180 degree rotation method
Proseal LMA, a variant of the classic LMA offers certain
distinctive advantages. It offers better seal, better inflation pressure and
the ability to decompress the stomach by passing a gastric tube through
the drain tube. The literature was searched and reviewed for using PLMA/
ETTin laparoscopic surgery.
44
1. MILLER DM, COMPOROTAL, et al IN 2006
Compared the efficacy of PLMA and SLIPA supra laryngeal
airways (SLA) with standard tracheal tube in 150 patients undergoing
daycare laparoscopic gynaecological surgery requiring general
anaesthesia.
An identical GA technique was used in all patients apart from the
addition of muscle relaxants and reversal drugs in ETT group. Ease of use,
quality of seal, ventilation, systolic pressure, response to intubation, side
effects and operating room time were assessed.
Both PLMA and SLIPA were easy to insert (100% success) and
ventilation with respective maximum sealing pressures of 31 and
30cmH2O (P= 0.4) with no muscle relaxants. The seal quality is both
PLMAand SLIPA permitted the use of low flows, 485 (291) and 539 (344)
mlx min(-1) (P= 0.2) respectively, although in the ETT group significantly
lower flows (377) (124 mlx min (-1) (P<0.01) were achieved.
Systolic pressure in the SLA group was more stable in response to
insertion than in ETT gp with PLMA, there was a lower incidence of
sorethroat than with ETT gp (30% vs 57%) (P< 0.05) and less difference
with SLIPA(30% vs 49%) (P>0.05).
With both SLA there was a significant reduction in operating room
time (> 3mts) (P<0.001).
45
The concluded that PLMA (reusable) and SLIPA (Single use) SLA’s
were easy to use without requiring muscle relaxants and less operating
room time compared to tracheal tube in daycare laparoscopies.
2. SHIN WJ, CHEONG YS, YANG HS:
(European Journal of Anaesthesia 2009 Nov.12)
Shin.wj and colleague compared PLMA(43), I-GEL and LMA-C to
assess insertion success rate , hemodynamic changes, seal pressure and
postop complication. They found that insertion success rate was similar in
these groups. There was no significant hemodynamic changes occurred in
these groups during insertion. The leak pressure was higher in both I- GEL
and Proseal LMA than the LMA- C. The postoperative complications
like sore throat were higher in LMA-C than other 2 devices (European
Journal of Anaesthesia 2009 Nov.12).
3. GIUSEPPE NATALINI MD,GABRIELLA LANZA MD,
ANTONIO ROSANO MD, et al IN 2002
Compared the frequency of airway seal and sorethroat(44) with
PLMA and std. LMA in 60 adults, ASA I, II & III patients undergoing
laparoscopic surgery under GA with controlled ventilation (Tidal volume
7ml/Kg, PEEP- 10cm H2O).
HR, BP, inspiratory and expiratory tidal volume, airway pressure,
EtCO2 and SpO2 were recorded. Leak fraction was calculated as the
46
difference between inspiratory and expiratory tidal volume divided by
inspiratory tidal volume. Postoperative sorethroat frequency was scored in
the recovery room (early) and 1 week after surgery (Late).
Leak fraction was 7+3% with LMA and 7+4% with PLMA
(P=0.731). Frequency of sorethroat is mild in 13% and 10% of patients
with LMA and PLMA respectively during the recovery room stay.
Hence they concluded that PLMA and LMA show similar air tight
efficiency and sorethroat evaluation performed in recovery room appears
as reliable as later evaluation.
47
MATERIALS AND METHODS
After obtaining institutional ethical committee approval this
prospective randomized study conducted in our institution. After getting
written informed consent 60 patients randomly alloted into 2 groups.
Group P – will receive proseal LMA
Group E – will receive Endotracheal tube intubation
INCLUSION CRITERIA
Either sex,
Age 20-65 years,
Body weight 40 – 75kg.
EXCLUSION CRITERIA
Pregnant Patients
Anticipated difficult airway
Obesity (BMI > 35kg/m2)
Oropharyngeal pathology,
Cardiopulmonary disease,
Cervical spine fracture or instability
Gastro-esophageal reflex disease
48
Anaesthesia Protocol:
A thorough preanaesthetic evaluation was done including history &
general examination.
All patients will receive T. Alprazolam 0.5mg and T.Ranitidine
150mg on the night before surgery and standard nil per oral protocol
followed. Patients shifted to OT, an IV line was secured with 18g venous
cannula, and an infusion of ringer lactate solution was started.
The patients connected to the monitor and the pre induction Systolic
BP, Diastolic BP, MAP, Heart rate, SPO2 are recorded.
Inj. Glycopyrrolate 0.01mg/kg iv, Inj. Midazolam 0.025mg/kg iv
will be given as premedication. Preoxygenation with 100%O2 for 3min
Patient induced with Inj. Fentanyl 2mcg/kg iv, Inj. Propofol 2mg/kg
iv, Inj. Lidocaine 1mg/kg iv and Inj. Succinyl Choline 2mg/kg iv. After an
adequate depth of anaesthesia is achieved, Proseal LMA is inserted by
index finger insertion method and connected to the anaesthetic machine
after confirming correct placement.
If the device insertion is not achieved, 2 extra attempts of placing
should try. If placements are unsuccessful after 3 attempts, the procedure
is discarded and the airway will be secured through other airway device
as appropriate and this case will be considered as a failed attempt.
The Proseal LMA was inserted by index finger insertion method.
The cuff was inflated with 20ml of air. Ventilation will be judged to be
49
optimal with sufficient chest rise, constant oxygenation SPO2 greater than
95% and absence of leak.
Successful placement of PLMA is defined by the following criteria
1. Square wave pattern on capnography
2. No air leak over mouth, stomach, drain tube
3. Positive suprasternal notch tap test.
4. Effective ventilation (TV> 8ml/Kg, EtCO2<45 mmHg).
Endo Tracheal Tube was inserted using chin lift position.
Ventilation will be judged to be optimal with sufficient chest rise, constant
oxygenation SPO2 greater than 95% and absence of leak.
Maintenance of anaesthesia done by N2O:O2-66:33%, Sevoflurane
0.25-1% along with Inj. Vecuronium 0.1mg/kg depending upon the need
and depth of anaesthesia for that surgery.
All patients were monitored continuously. At the end of procedures,
residual neuromuscular blockade was reversed with Inj. Neostigmine
0.05mg/Kg and Inj. Glycopyrolate 0.01mg/Kg and the Proseal LMA (or)
Endo Tracheal Tube was removed after adequate recovery of muscle
power.
The patient shifted to postoperative ward after full recovery.
50
Parameter evaluated:
All patients will be monitored continuously for
Heartrate – preoperative, intraoperative and after insertion, after
pneumoperitoneum, after removal of device.
Mean Arterial Pressure and ETCO2–preoperative, intraoperative,
after insertion, after pneumoperitoneum, after removal of device.
SPO2- preoperative, intraoperative, after insertion, after
pneumoperitoneum, after removal of device.
The ease of insertion, number of attempts and duration every try
(time from taking the device to checking of bilateral airway).
The leak can be tested by placing the stethoscope over mouth,
epigastrium and drain tube end to hear any leak.
Post operatively each patient will be questioned for the following
complications
Throat pain, sore throat.
Dysphagia.
Dysphonia (difficulty (or) pain with speaking).
Nausea and vomiting.
Hoarseness of voice.
51
Complication such as incidence of any airway complication will be
evaluated
Postextubation cough,
Breath holding,
Laryngospasm.
Bronchospasm, regurgitation.
Presence of blood on the devices
Lip, oralmucosal, pharynx trauma.
All cases will be questioned to verify any of the complications in postop
room & 24hrs postoperatively.
Sorethroat, throatpain
Nausea, vomiting
Dysphagia.
Hoarseness of voice.
Followup period:
Patient will be followed up for 24hrs in post-operative ward to verify
any complications.
Statistical analysis:
The data will be analysed using SPSS version 16.0 for windows 7.
52
RESULTS
A total of 60 patients were subjected to anesthesia by two different
anesthesia delivery devices namely Proseal Laryngeal Mask Airway and
the standard cuffed Endo Tracheal Intubation.
The following are the observations of the study.
Demographic profile
The mean age among all the respondents was 38.02 years with a
standard deviation of ± 13.584. The minimum age group encountered was
18 years and the maximum was 65 years. Female subjects were more
58.3% in comparison to males 41.7%.
53
Table 7 : Demographic profile of study participants
Age group Number (n) Percentage (%)
< 20 years 3 5.0
20 – 35 years 26 43.3
36 – 50 years 18 30.0
51 – 65 years 13 21.7
Sex
Male 25 41.7
Female 35 58.3
Figure : 18 Age distribution among study participants
54
Table 8 : Age and Sex distribution among PROSEAL LMA and ETT
Age group PROSEAL LMA ETT
Number (percentage) Number (percentage)
< 20 years 1 (3.3) 2 (6.7)
20 – 35 years 15 (50.0) 11 (36.7)
36 – 50 years 10 (33.3) 8 (26.7)
51 – 65 years 4 (13.3) 9 (30.3)
Total 30 (100) 30 (100)
Sex
Male 12 (40.0) 13 (43.3)
Female 18 (60.0) 17 (56.7)
Figure : 19 Age distribution among PLMA and ETT Groups
55
Statistical analysis: PROSEAL LMA vs ETT
The mean age of the respondents who received PROSEAL LMA is
35.73 years while those in the ETT group had a mean age of 40.30. The
difference in the mean age of the PROSEAL LMA and ETT groups is
4.567 years and this difference is not statistically significant (p= 0.195).
Hence both the groups are comparable in terms of age distribution.
Table 9 : Age difference between PLMA and ETT
Group No Mean SD Mean
Difference
p
value
95% confidence
interval
Upper Lower
PROSEAL
LMA
30 35.73 ± 12.798 4.567 0.195 2.412 11.545
ETT 30 40.30 ± 14.172
56
Table 10 : Average number of attempts
Group No 1st attempt 2nd attempt Odd’s
ratio
p value
PROSEAL
LMA
30 28 2 1.56 0.038
ETT 30 27 3
PLMA insertion was successful in 28/30 cases in first attempt, while
2 /30 patients required second attempt. With ETT 27/30 had successful
intubation during first attempt and 3/30 had second attempt.
Using a PROSEAL LMA had 1.56 less chances of intubation during
second attempt when compared to ETT and this association between
reintubation and PROSEAL LMA was statistically significant with a p
value of 0.038 (p< 0.05).
57
Table 11 : Time taken for insertion
Group No Mean SD p value
PROSEAL LMA 30 13.30 ± 3.042 0.0012
ETT 30 16.17 ± 3.445
The time taken for PLMA/ETT includes time taken from
introduction into oral cavity to the final confirmation of its proper
positioning. Time taken for intubation with PLMA is 13.30 seconds and
with ETT is 16.17 seconds. Proseal LMA inserted 3 seconds earlier than
Endotracheal tube intubation and P value indicates that this difference is
statistically significant.
Table 12: Ryle’s Tube insertion- number of attempts
Attempts PLMA ETT
1st Attempt 28(93.3%) 22 (73.3%)
2nd Attempt 2(6.67%) 6 (20%)
3rd Attempt - 2(6.67%)
58
The number of attempts at insertion of Ryle’s tube insertion
was successful in 1st attempt using PLMA as it gave a separate
channel for isolating the digestive tract. Further the insertion of
Ryle’s tube was possible in 6.67% of subjects with 3 rd attempt when
using ETT as the intubating device. This shows the ease with which
Ryle’s tube may be inserted when using PLMA as the intubating
device.
Figure : 20
59
Table 13: Time taken for insertion of Ryle’s Tube
Group No Mean SD p value
PROSEAL
LMA
30 11.13 ± 2.014 0.0004
ETT 30 13.12 ± 2.117
Figure : 21 Ryle’s Tube Insertion time
Time taken for intubation with PLMA is 11.30 seconds and with
ETT is 13.12 seconds. Student’s t test reveals P value of 0.0004 which is
significant. This indicates there is difference in Ryle’s tube insertion time
between PLMA and ETT which is statistically significant.
60
POSTOPERATIVE AIRWAY MORBIDITY
Table 14: Postoperative Airway Morbidity
Groups Yes No Mean
Standard
Deviation
Sore
Throat
PLMA 1 29 1.96 0.20
0
t=1.41
P=0.161 Not
Significa
nt
ETT 4 26 1.84 0.37
4 Laryngo
Spasm
PLMA 0 0 2.00 0.
0
Not significant
ETT 0 0 2.00 0.0
0
Postoperative sorethroat and laryngospasm were assessed for 24
hours postoperatively. Sorethroat occurred in 1/30 cases with PLMA and
4/30 cases with ETT. Laryngospasm did not occur in both the groups.
Through documented data are clinically relevant statistical analysis reveals
P Value of 0.164 which is not significant. Hence incidence of postoperative
airway morbidity is same in both the groups.
Heart rate
Mean heart rate during preinduction time for PROSEAL LMA is
83.10 bpm and that of ETT is 88.80 bpm. The mean heart rates at 10
seconds, 1 minute, 3 minutes and 5 minutes after insertion of PROSEAL
LMA were 85.30, 80.47, 80.27 and 82.03 bpm respectively while the mean
heart rates at 10 seconds, 1 minute, 3 minutes and 5 minutes after insertion
of ETT were 87.43, 87.93, 90.53 and 89.03 bpm. Statistical analysis shows
61
that p values for preinduction heart rates, heart rates at 10 seconds, 1 minute
after insertion of PROSEAL LMA was 0.081, 0.0540 and 0.076 and were
not statistically significant. However, the p values for heart rates at 3 and
5 minutes after insertion of PROSEAL LMA was 0.012 and 0.033 and is
statistically significant thereby showing that there is difference in the mean
heart rates after insertion of PROSEAL LMA and ETT. The mean heart
rate following pneumoperitoneum was 87 bpm in PROSEAL LMA group
and 88.70 in the ETT group. The difference in mean heart rates following
pneumoperitoneum was not statistically significant with a p value of 0.666.
The mean heart rates following extubation was 88.43 and 95.43 bpm in the
PROSEAL LMA and ETT groups respectively. This difference in heart
rates following extubation was statistically significant with a p value of
0.018 (<0.05)
62
Table 15: Hemodynamic Response – Heart Rate
Group No Mean SD p value
Preinduction
PROSEAL
LMA 30 83.10 ± 11.028 0.081
ETT 30 88.80 ± 13.659
10 secs after
PROSEAL
LMA 30 85.30 ± 12.863 0.0540
ETT 30 87.43 ± 13.908
1 min after
PROSEAL
LMA 30 80.47 ± 17.585 0.076
ETT 30 87.93 ± 14.246
3 min after
PROSEAL
LMA 30 80.27 ± 17.213 0.012
ETT 30 90.53 ± 13.198
5 min after
PROSEAL
LMA 30 82.03 ± 12.607 0.033
ETT 30 89.03 ± 12.263
After
pneumoperitoneum
PROSEAL
LMA 30 87.00 ± 14.494 0.666
ETT 30 88.70 ± 15.853
After extubation
PROSEAL
LMA 30 88.43 ± 10.013 0.018
ETT 30 95.93 ± 13.595
63
Figure : 22
Figure : 23
0
20
40
60
80
100
120
140
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Heart Rate - PLMA Group
10 seconds 1 min 3 min
5 min after pneumopritoneum after extubation
0
20
40
60
80
100
120
140
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Heart Rate - ETT Group
10 sec 1 min 3 min
5 min after pneumoperitoneum after extubation
64
Mean Arterial Blood Pressure
Mean arterial pressure during preinduction time for PROSEAL
LMA is 88.87mmHg and that of ETT is 94.70mmHg. The mean arterial
pressure at 10 seconds, 1 minute, 3 minutes and 5 minutes after insertion
of PROSEAL LMA were 86.53, 83.03, 84.57, and 83.77mmHg
respectively while the mean heart rates at 10 seconds, 1 minute, 3 minutes
and 5 minutes after insertion of ETT were 89.67, 88.60, 84.73 and 87.10
mmHg. Statistical analysis shows that p values for preinduction Mean
arterial pressure, at 10 seconds, 1 minute, 3 minutes and 5 minutes after
insertion of PROSEAL LMA was 0.088, 0.320, 0.094,0.961 and 0.324 and
were not statistically significant. The mean arterial pressure values
following pneumoperitoneum and extubation were 91.50 and 102.93
mmHg for the PROSEAL LMA group and 94.47 and 100.43 for the ETT
groups respectively. The p values for heart rates after pneumoperitoneum
following PROSEAL LMA was 0.013 and is statistically significant
thereby showing that there is difference in the mean arterial pressure
following pneumoperitoneum after insertion of PROSEAL LMA and ETT.
65
Table 16: Haemodynamic response – Mean arterial pressure
Group No Mean
(mmHg)
SD p value
Preinduction
PROSEAL
LMA
30 88.87 ± 14.137 0.088
ETT 30 94.70 ± 11.742
10 secs after
PROSEAL
LMA
30 86.53 ± 13.182 0.320
ETT 30 89.67 ± 10.902
1 min after
PROSEAL
LMA
30 83.03 ± 14.495 0.094
ETT 30 88.60 ± 10.506
3 min after
PROSEAL
LMA
30 84.57 ± 15.348 0.961
ETT 30 84.73 ± 10.422
5 min after
PROSEAL
LMA
30 83.77 ± 13.913 0.324
ETT 30 87.10 ± 11.978
After
pneumoperitoneum
PROSEAL
LMA
30 91.50 ± 15.104 0.013
ETT 30 102.93 ± 19.278
After extubation
PROSEAL
LMA
30 94.47 ± 11.554 0.070
ETT 30 100.43 ± 13.434
66
Figure : 24
Figure : 25
0
20
40
60
80
100
120
140
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Mean Arterial Pressure - PLMA Group
10 sec 1 min 3 min 5 min after pneumoperitoneum after extubation
0
50
100
150
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Mean Arterial Pressure - ETT Group
10 sec 1 min' 3 min
5 min after pneumoperitoneum after extubation
67
ETCO2
ETCO2 during preinduction time for PROSEAL LMA is
30.20mmHg and that of ETT is 30.13mmHg. ETCO2 at 10 seconds, 1
minute, 3 minutes and 5 minutes after insertion of PROSEAL LMA were
31.16, 30.74, 31.80, 32.21 and 31.90 mmHg respectively while the mean
heart rates after insertion of ETT at 10 seconds, 1 minute, 3 minutes and 5
minutes were 30.74, 30.74, 30.75 and 30.57 mmHg. The ETCO2 values
following pneumoperitoneum and extubation were 33.74 and 32.96 mmHg
for the PROSEAL LMA group and 31.51 and 32.81 for the ETT groups
respectively. The p values for ETCO2 after pneumoperitoneum and
extubation following PROSEAL LMA was 0.080 and 0.881 and is
statistically not significant thereby showing that there is no difference in
the ETCO2 levels following pneumoperitoneum and extubation between
the two groups.
68
Figure : 26
Figure : 27
0
10
20
30
40
50
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
ETCO2 PLMA
10 sec 1 min 3 min
5 min after pneumoperitoneum after extubation
0
10
20
30
40
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
ETCO2 - ETT
10 sec 1 min 3 min
5 min after pneumoperitoneum after extubation
69
Table 17: Haemodynamic response – ETCO2
Group No Mean SD p value
Preinduction
PROSEAL
LMA 30 30.20 ± 3.827 0.946
ETT 30 30.13 ± 3.730
10 secs after
PROSEAL
LMA 30 31.16 ± 3.097 0.657
ETT 30 30.74 ± 4.172
1 min after
PROSEAL
LMA 30 31.80 ± 3.210 0.230
ETT 30 30.74 ± 3.567
3 min after
PROSEAL
LMA 30 32.21 ± 3.504 0.140
ETT 30 30.75 ± 4.016
5 min after
PROSEAL
LMA 30 31.90 ± 3.722 0.223
ETT 30 30.57 ± 4.554
After
pneumoperitoneum
PROSEAL
LMA 30 33.74 ± 4.500 0.080
ETT 30 31.51 ± 5.167
After extubation
PROSEAL
LMA 30 32.96 ± 3.978 0.881
ETT 30 32.81 ± 3.777
70
DISCUSSION
The study conducted to compare the two-airway device Proseal
LMA and Endo Tracheal Tube (ETT) in view of ease of insertion, number
of attempts, hemodynamic changes and postoperative adverse events. The
study was conducted to 60 patients of both sexes aged 18–65 years going
for elective surgical procedures with spontaneous ventilation. Both the
devices provide patent airway during PPV(45,46). Both devices also reduce
the incidence of gastric insufflations and regurgitation.(47)
DEMOGRAPHIC PROFILE
Age distribution
The above study shows that the mean age group of Proseal LMA
is 35.73 years and that of ETT is 40.30 respectively and this difference
in age between the two groups is not statistically significant (P˃0.05). This
shows that both the groups have similar distribution of age and the
difference noted is because of chance. Studies by Malby et al(48) comparing
PLMA with ETT on patients undergoing laproscopic cholecystectomy
also show similar age group profiles with mean age among PLMA being
38.12 and ETT being 41.22 years respectively. Similarly Randomized
Controlled studies by Griffiths et al(49) on comparison of Proseal LMA and
ETT also showed similar age group patterns with mean age among PLMA
71
subjects was 34.75 and that of ETT being 38.21 years respectively.
Sex distribution
In this study is 12/30 and 18/30 respectively. Similarly the
distribution of male and female subjects in ETT group is 13/30 and 17/30
respectively. Studies by Maltby et al also have similar sex distribution
among respondents.
NUMBER OF ATTEMPTS TO SUCCESSFUL PLACEMENT
Studies by Evans.N, Gardner.S.V et al(50) in 300 patients assessed
the insertion characteristics, airway seal pressures etc using proseal LMA
have shown that insertion was successful in 94% of patients and easy in 91
% of patients. The findings of our study are in concurrence with the above
data. The success rate of PLMA was 95% in our study and it had 1.56 times
less chances of 2nd intubation when compared to ETT and this association was
statistically significant with a the P value of 0.038. Miller DM, camporotaL,
etal(51) in 2006 compared PLMA and SLIPA with ETT in 150 patients. Both
PLMA and SLIPA were inserted in 1st attempts (100% success) and
ventilated with maximum sealing pressure of 30cm H2O (P=0.4) with no
muscle relaxant.
72
TIME TAKEN FOR INTUBATION
Miller DM, CamporotaL, et al(51) in 2006 compared PLMA, SLIPA
with ETT in 150 anaesthetised patients undergoing daycare laparoscopic
surgery. They concluded PLMA and SLIPA were easy to use and less
operating room time (P=< 0.001) was required compared to ETT in
daycare laparoscopies. In our study a mean difference of 2.80 seconds is
noted between use of PLMA and ETT and this difference was found to be
statistically significant (P= 0.0012).
PULMONARY VENTILATION
Roger Maltby, Michael Beriauletal(48) in 2002 analysed PLMA and
ETT in 109 patients undergoing laparoscopic cholecystectomy and
concluded no statistically significant differencein SpO2/ EtCO2 between
two groups. This result is comparable with our study result which shows
no significant EtCO2 changes (P= 0.946, 0.657, 0.230, 0.140, 0.223)
measured Pre-op, Pre intubation, 1mt, 3mt and 5mt after intubation, after
peritoneal inflation and after extubation. J. Roger Maltby,(45)et al,
compared PLMA and ETT in 209 women undergoing laparoscopic
gynaecological surgery, concluded no statistically significant difference
between PLMA and ETT groups for SpO2, EtCO2 before or during
peritoneal insufflation in short and long period of peritoneal inflation. The
results are comparable with our study.
73
POST OPERATIVE AIRWAY MORBIDITY
In our study sorethroat occurred 4/30 cases with ETT while it
occurred only in 1 patient out of 30 in the PLMA group. Laryngospasm
did not occur in both the groups. Through documented data are clinically
relevant statistical analysis reveals P Value of 0.176 which is not
significant. Though there is difference in incidence of post operative
airway morbidity especially with regard to sore throat, it is nor statistically
significant and hence we conclude that the post operative airway
morbidity is the same in both the groups. However studies by Miller DM,
Camporota. L, et al(51) in 2006 in their study on 150 patients, concluded
that lower incidence of sorethroat with PLMA than with ETT group (30%
Vs 57% and P value < 0.05).This might be due to the lesser sample size in
our study with 60 patients compared to 150 patients. Hohlrieder M,
Brimacombe J, et al(52) in 2007 compared PLMA with ET in 200 female
patients, concluded that less frequency of sorethroat with PLMA (12% Vs
38%, P <0.001). Though this result is comparable with our study statistical
significance was not achieved due to smaller sample size.
HEMODYNAMIC CHANGES
Mean arterial pressure changes were noted in our study especially
after pneumoperitoneum following use of Proseal LMA and ETT and this
difference is statistically significant with P values of 0.013 thereby making
74
it evident that use of PLMA is associated with less chances of increase of
mean arterial pressure. Studies by Vannila et al(53) shows an increase in
Mean Arterial Pressure increased in the ETT group, but however the
hemodynamic changes were reflected in other parameters like changes
at 10 seconds, 1 minute, 3 minutes and following extubation. In our
study though there was difference in the mean arterial pressure values
between PLMA and ETT, with a lower values being recorded with PLMA
the difference was not statistically significant. Similarly studies by Kiran
et al(23) showed that the values of mean arterial pressure after LMA
insertion were significantly lower compared to tracheal intubation after
1,3 and 5 minutes when compared to ETT insertion.
The heart rate changes were much less in the PLMA group
compared to ETT group and these differences in heart rate is statistically
significant at 3 minutes, 5 minutes and after extubation with P values of
0.012, 0.033 and 0.018. These findings are consistent with studies done
by Songsong Mao et al(54) on intubation characteristics between laryngeal
mask airway and endotracheal intubation for anesthesia in adult patients
undergoing laparoscopic surgeries.
75
SUMMARY
The present study was conducted with the aim to compare the
intubation characteristics between Proseal LMA and Endo Tracheal Tube
among patients posted for laparoscopic surgeries in Department of
Anaesthesiology, Government Theni Medical College & Hospital, Theni.
Totally 60 patients posted for elective surgeries were selected those who
fulfill the inclusion criteria. Prospective randomized clinical trial study
design was adopted. The study design selected for this study was
systematic random sampling. The protocol was prepared based on the
guidelines. Ethical clearance was obtained from the Institutional Ethical
Committee. Informed consent was obtained after explaining the purpose
of the study. The data was collected from March 2018 to May 2019. The
study population was divided into 2 groups in which Proseal LMA was
used for intubation in Group P and Group E Endo Tracheal Tube was
used. Hemodynamic parameters like Blood pressure (systolic, diastolic
and mean arterial pressure), Heartrate and Oxygen saturation were
recorded at Baseline, 10seconds, 1minute, 3minute, 5 minute, after
pneumoperitoneum and after extubation. Duration of Proseal LMA
insertion [from the period of insertion of LMA to the checking of bilateral
air entry] was recorded.
76
Results showed that there was no statistical significant difference in mean
age, gender distribution, weight, diagnosis and ASA risk between two
groups and hence all the two groups were comparable.
The use of Proseal LMA may offer some advantages over
endotracheal intubation especially in the management of pressor response
where the control of mean arterial pressure plays a vital role.
The changes in mean heart rate were much lesser in the Proseal
LMA group compared to ETT group with the difference being significant
at 3 min, 5 min and after extubation. This could prove of P value especially
in patients whose heart rate monitoring requires intensive management
principles following surgical procedures.
77
CONCLUSION
Results of this study suggest that patients intubated using Proseal LMA
have desirable hemodynamic stability compared to patients intubated using
Endo Tracheal Tube. In addition to the favorable side effect profile, lesser
intubation time, ease of insertion of Ryle’s tube and airway maintenance though
was better in the PLMA group. Due to the significant difference in various
parameters observed with Proseal LMA in comparison to ETT, it may be stated
that the proseal LMA is a better intubation device compared to ETT thereby
proving its efficacy.
78
LIMITATIONS
This study excluded the patients with airway problems, as these
patients require longer intubation time, which can result in different
outcomes.
This study was conducted on patients with ASA I and II. Making
such comparisons on patients with underlying cardiac diseases may
bringout different results.
Depth of anaesthesia was not monitored in the study.
Plasma corticosteroid concentrations were not measured.
ANNEXURE - I
BIBLIOGRAPHY
1. McNarry AF, Patel A. The evolution of airway management – new concepts
and conflicts with traditional practice. British Journal of Anaesthesia. 2017
Dec;119:i154–66.
2. Cook TM. Editorial I: The classic laryngeal mask airway: a tried and tested
airway. What now? British Journal of Anaesthesia. 2006 Feb;96(2):149–52.
3. Constantino SK, Waisel DB. The History of the Endotracheal Tube, from
Concept to Modern Design. Journal of Anesthesia History. 2018
Jan;4(1):51.
4. Singh A, Bhalotra AR, Anand R. A comparative evaluation of ProSeal
laryngeal mask airway, I-gel and Supreme laryngeal mask airway in adult
patients undergoing elective surgery: A randomised trial. Indian Journal of
Anaesthesia. 2018 Nov;62(11):858.
5. Imai M, Matsumura C, Hanaoka Y, Kemmotsu O. Comparison of
cardiovascular responses to airway management: Fiberoptic intubation
using a new adapter, laryngeal mask insertion, or conventional
laryngoscopic intubation. Journal of Clinical Anesthesia. 1995
Feb;7(1):14–8.
6. Dyer RA, Llewellyn RL, James MFM. Total i.v. anaesthesia with propofol
and the laryngeal mask for orthopaedic surgery. British Journal of
Anaesthesia. 1995 Feb;74(2):123–8.
7. Levine AI, DeMaria S. An Updated Report by the American Society of
Anesthesiologists Task Force on Management of the Difficult Airway:
Where Is the Aspiration Risk Assessment? Anesthesiology. 2013
Sep;119(3):731–2.
8. Brimacombe J, Brain AIJ. The laryngeal mask airway: Current Opinion in
Anaesthesiology. 1995 Dec;8(6):478–84.
9. Sung A, Kalstein A, Radhakrishnan P, Yarmush J, Raoof S. Laryngeal
Mask Airway: Use and Clinical Applications: Journal of Bronchology. 2007
Jul;14(3):181–8.
10. Brain AIJ, Verghese C, Strube PJ. The LMA ‘ProSeal’—a laryngeal mask
with an oesophageal vent. British Journal of Anaesthesia. 2000
May;84(5):650–4.
11. Cook TM, Lee G, Nolan JP. The prosealTMlaryngeal mask airway: a review
of the literature. Can J Anesth/J Can Anesth. 2005 Aug;52(7):739–60.
12. Choudhary DRC, Agrawal MAR. Importance of Anaesthesiology in Indian
Healthcare: A Review. 2017;6.
13. Agarwal A. The future of anaesthesiology. Indian J Anaesth.
2012;56(6):524.
14. The Role of the Anesthesiologist [Internet]. [cited 2019 Oct 8]. Available
from: https://www.tsa.org/public/anesthesiologist_role.php
15. Meena K, Meena R. A Comparative Study of Effect of Propofol, Etomidate
and Propofol Plus Etomidate Induction on Hemodynamic Response to
Endotracheal Intubation: A RCT. J Anesth Clin Res [Internet]. 2016 [cited
2019 Oct 8];07(05). Available from: https://www.omicsonline.org/open-
access/a-comparative-study-of-effect-of-propofol-etomidate-and-propofol-
plusetomidate-induction-on-hemodynamic-response-to-endotracheal-i-
2155-6148-1000622.php?aid=74100
16. Stevenson AGM, Graham CA, Hall R, Korsah P, McGuffie AC. Tracheal
intubation in the emergency department: the Scottish district hospital
perspective. Emergency Medicine Journal. 2007 Jun 1;24(6):394–7.
17. Wakeling HG, Butler PJ, Baxter PJC. The Laryngeal Mask Airway: A
Comparison Between Two Insertion Techniques. Anesthesia & Analgesia.
1997 Sep;85(3):687–90.
18. Dwarkadas K Baheti V v L. Understanding anesthetic equipment &
procedures. 2nd ed. Vol. 16. Jaypee; 2015. 578 p.
19. Goksu S, Şen E. History of Intubation. In 2015.
20. White GMJ. EVOLUTION OF ENDOTRACHEAL AND
ENDOBRONCHIAL INTUBATION. British Journal of Anaesthesia. 1960
May;32(5):235–46.
21. Hadenfeldt SL. A Historical Study of Nurse Anesthesia Education in
Nebraska. :295.
22. Gillespie NA. The Evolution of Endotracheal Anaesthesia. J Hist Med
Allied Sci. 1946;1(4):583–94.
23. Montazari K, Naghibi K, Hashemi SJ. COMPARISON OF
HEMODYNAMIC CHANGES AFTER INSERTION OF LARYNGEAL
MASK AIRWAY, FACEMASK AND ENDOTRACHEAL
INTUBATION. :4.
24. Prys-Roberts C, Greene LT, Meloche R, Foëx P. STUDIES OF
ANAESTHESIA IN RELATION TO HYPERTENSION II:
HAEMODYNAMIC CONSEQUENCES OF INDUCTION AND
ENDOTRACHEAL INTUBATION. British Journal of Anaesthesia. 1971
Jun;43(6):531–47.
25. Takahashi S, Mizutani T, Miyabe M, Toyooka H. Hemodynamic Responses
to Tracheal Intubation with Laryngoscope Versus Lightwand Intubating
Device (Trachlight®) in Adults with Normal Airway: Anesthesia &
Analgesia. 2002 Aug;95(2):480–4.
26. Miller. Miller’s Anesthesia International Edition 2 Volume Set. 8 edition.
Philadelphia, PA: Elsevier Health - US; 2014. 3576 p.
27. Khan DR. Airway Management 6th Edition. 6th ed. Paras medical
publisher; 2018.
28. Dunn PF, Goulet RL. Endotracheal Tubes and Airway Appliances:
International Anesthesiology Clinics. 2000;38(3):65–94.
29. Klučka J, Šenkyřík J, Skotáková J, Štoudek R, Ťoukalková M, Křikava I, et
al. Laryngeal mask airway UniqueTM position in paediatric patients
undergoing magnetic resonance imaging (MRI): prospective observational
study. BMC Anesthesiol. 2018 Dec;18(1):153.
30. White L, Melhuish T, Holyoak R, Ryan T, Kempton H, Vlok R. Advanced
airway management in out of hospital cardiac arrest: A systematic review
and meta-analysis. The American Journal of Emergency Medicine. 2018
Dec;36(12):2298–306.
31. Benumof JL. Laryngeal Mask Airway: Indications and Contraindications.
Anesthesiology. 1992 Nov;77(5):843–6.
32. Timmermann A, Bergner UA, Russo SG. Laryngeal mask airway
indications: new frontiers for second-generation supraglottic airways.
Current Opinion in Anaesthesiology. 2015 Dec;28(6):717–26.
33. Keller C, Pühringer F, Brimacombe JR. Influence of cuff volume on
oropharyngeal leak pressure and fibreoptic position with the laryngeal mask
airway. British Journal of Anaesthesia. 1998 Aug;81(2):186–7.
34. Clery G, Brimacombe J, Stone T, Keller C, Curtis S. Routine Cleaning and
Autoclaving Does Not Remove Protein Deposits from Reusable Laryngeal
Mask Devices: Anesthesia & Analgesia. 2003 Oct;1189–91.
35. Lewis S, McIndoe AK. Cleaning, disinfection and sterilization of
equipment. Anaesthesia & Intensive Care Medicine. 2004 Nov;5(11):360–
3.
36. Joshi S, Sciacca RR, Solanki D, Young WL, Mathru MM. A Prospective
Evaluation of Clinical Tests for Placement of Laryngeal Mask Airways.
Anesthes. 1998 Nov 1;89(5):1141–6.
37. Wong DT, Yang JJ, Mak HY, Jagannathan N. Use of intubation introducers
through a supraglottic airway to facilitate tracheal intubation: a brief review.
Can J Anesth/J Can Anesth. 2012 Jul;59(7):704–15.
38. El Beheiry H, Wong J, Nair G, Chinnappa V, Arora G, Morales E, et al.
Improved esophageal patency when inserting the ProSealTM laryngeal mask
airway with an EschmannTM tracheal tube introducer. Can J Anesth/J Can
Anesth. 2009 Oct;56(10):725–32.
39. Stix MS, O’Connor CJ. Depth of insertion of the ProSealTM laryngeal mask
airway. British Journal of Anaesthesia. 2003 Feb;90(2):235–7.
40. O’Connor CJ, Davies SR, Stix MS. “Soap Bubbles” and “Gauze Thread”
Drain Tube Tests: Anesthesia & Analgesia. 2001 Oct;93(4):1082.
41. O’Connor CJ, Borromeo CJ, Stix MS. Assessing ProSeal Laryngeal Mask
Positioning: The Suprasternal Notch Test: Anesthesia & Analgesia. 2002
May;94(5):1374–5.
42. Xue FS, Mao P, Liu HP, Yang QY, Li CW, He N, et al. The effects of head
flexion on airway seal, quality of ventilation and orogastric tube placement
using the ProSealTM laryngeal mask airway*: The effects of head flexion on
position and performance of the ProSealTM laryngeal mask airway.
Anaesthesia. 2008 Aug 6;63(9):979–85.
43. Shin W-J, Cheong Y-S, Yang H-S, Nishiyama T. The supraglottic airway
I-gel in comparison with ProSeal laryngeal mask airway and classic
laryngeal mask airway in anaesthetized patients: European Journal of
Anaesthesiology. 2010 Jul;27(7):598–601.
44. Natalini G, Lanza G, Rosanò A, Dell’Agnolo P, Bernardini A. Standard
Laryngeal Mask Airway TM and LMA-ProSeal TM during Laparoscopic
Surgery. In 2003.
45. Maltby JR, Beriault MT, Watson NC, Liepert DJ, Fick GH. LMA-ClassicTM
and LMA-ProSealTM are effective alternatives to endotracheal intubation
for gynecologic laparoscopy. Can J Anesth/J Can Anesth. 2003
Jan;50(1):71–7.
46. Natalini G, Franceschetti ME, Pantelidi MT, Rosano A, Lanza G,
Bernardini A. Comparison of the standard laryngeal mask airway and the
ProSeal laryngeal mask airway in obese patients. British Journal of
Anaesthesia. 2003 Mar;90(3):323–6.
47. Zoremba M, Aust H, Eberhart L, Braunecker S, Wulf H. Comparison
between intubation and the laryngeal mask airway in moderately obese
adults. Acta Anaesthesiologica Scandinavica. 2009 Apr;53(4):436–42.
48. Maltby JR, Beriault MT, Watson NC, Liepert D, Fick GH. The LMA-
ProSealTM is an effective alternative to tracheal intubation for laparoscopic
cholecystectomy. Can J Anesth/J Can Anesth. 2002 Oct;49(8):857–62.
49. Griffith OW. Biologic and pharmacologic regulation of mammalian
glutathione synthesis. Free Radical Biology and Medicine. 1999 Nov;27(9–
10):922–35.
50. Evans NR, Gardner SV, James MFM, King JA, Roux P, Bennett P, et al.
The ProSeal laryngeal mask: results of a descriptive trial with experience of
300 cases † †Declaration of interest. Marland Medical South Africa funded
the salary of a research assistant and provided the masks. AstraZeneca
(South Africa) provided the propofol used for this study. ‡LMA® is the
property of Intavent Limited. British Journal of Anaesthesia. 2002
Apr;88(4):534–9.
51. Miller DM, Camporota L. Advantages of ProSealTM and SLIPATM airways
over tracheal tubes for gynecological laparoscopies. Can J Anesth/J Can
Anesth. 2006 Feb;53(2):188–93.
52. Eschertzhuber S, Brimacombe J, Hohlrieder M, Keller C. The Laryngeal
Mask Airway Supreme TM - a single use laryngeal mask airway with an
oesophageal vent. A randomised, cross-over study with the Laryngeal Mask
Airway ProSeal TM in paralysed, anaesthetised patients. Anaesthesia. 2009
Jan;64(1):79–83.
53. Chopra1 V, Gupta2 V, Lone3 AQ, Naqash4 IA. Endotracheal Intubation,
Laryngeal Mask Airway, Haemodynamics. COMPARISON OF
HAEMODYNAMIC CHANGES IN RESPONSE TO ENDOTRACHEAL
INTUBATION AND LARYNGEAL MASK AIRWAY IN
CONTROLLED HYPERTENSIVE PATIENTS- A RANDOMISED
STUDY [Internet]. 2017 Feb 27 [cited 2019 Oct 13];(12951). Available
from: https://jemds.com/latest-articles.php?at_id=12951
54. Mao S, Du X, Ma J, Zhang G, Cui J. A comparison between laryngeal mask
airway and endotracheal intubation for anaesthesia in adult patients
undergoing NUSS procedure. J Thorac Dis. 2018 Jun;10(6):3216–24.
ANNEXURE - II
MASTER CHART
ABBREVIATIONS USED IN MASTER CHART
PLMA Proseal Laryngeal Mask Airway
ETT Endo Tracheal Tube
A Age
S Sex
Int Intubation device used
Att Number of attempts at insertion
T Time for insertion of intubation device
RTA Number of attempts at insertion of Ryle’s tube
RT Time for insertion of Ryle’s tube
PI Pre induction
AP After Pneumoperitoneum
AE After extubation
ANNEXURE - III
ANNEXURE – IV
ETHICAL COMMITTEE APPROVAL CERTIFICATE
ANNEXURE - V
PLAGIARISM REPORT
ANTI PLAGIARISM CERTIFICATE
This is to certify that this dissertation work titled, entitled “COMPARISON
OF PROSEAL LARYNGEAL MASK AIRWAY AND ENDOTRACHEAL
TUBE IN PATIENTS UNDERGOING LAPAROSCOPIC SURGERIES”
submitted by Dr.K.MAYILVANAN with registration number 201720753 for the
award of MASTER DEGREE in the branch of ANAESTHESIOLOGY has been
personally verified by me in urkund.com website for the purpose of plagiarism check.
I found that the uploaded thesis file contains from introduction to conclusion pages
and result shows 14% percentage of plagiarism in the dissertation.
Guide and supervisor sign with seal
Prof. DR.M.BALASUBRAMANI,
MD., DA.,
Professor and Guide,
Department of Anaesthesiology,
Govt Theni Medical College,
Theni.