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The Laryngoscope

V C 2012 The American Laryngological,


Rhinological and Otological Society, Inc.

Laryngeal Mask Airway Versus Endotracheal Tube in Pediatric


Adenotonsillectomy

David I. Sierpina, MD; Hamad Chaudhary, MD; David L. Walner, MD, FAAP; Dana Villines, MA;
Karen Schneider, MD; Marissa Lowenthal, MD; Yuri Aronov, MD

Objectives/Hypothesis: Evaluation of safety and postoperative outcomes of the laryngeal mask airway (LMA) during
pediatric tonsil surgery compared to use of the endotracheal tube (ETT).
Study Design: Randomized controlled trial.
Methods: A population-based sample of 117 patients ages 2 to 18 years requiring adenotonsillectomy, adenoidectomy, or
tonsillectomy was studied. Evaluation forms covering 36 safety, surgery duration, and patient comfort variables were given to
the surgeon, anesthesiologist, and phase I and phase II recovery nurses to collect data on the intra- and postoperative
course. A phone survey was conducted 24 hours after surgery.
Results: At the a level following Bonferroni correction, LMA showed less coughing or gagging during the anesthesia
phase for all surgeries combined (48% for ETT vs. 20% for LMA; v 2 10.153, P .002), and for ETT nontonsillectomy vs.
LMA nontonsillectomy (48% for ETT vs. 3% for LMA; v 2 15.196, P .000), spontaneous ventilation was used more often in
the LMA group when comparing all surgeries (v2 19.493, P .000), and when comparing ETT tonsillectomy and LMA
tonsillectomy (v2 11.131, P .000).
Conclusions: Use of the LMA during pediatric tonsil surgery does not appear to have any major disadvantages
compared to use of the ETT. In fact, analysis of safety, comfort, complications, and postoperative problems suggests that
LMA may be superior for some outcome variables such as coughing and gagging. Use of spontaneous ventilation is more
common among LMA patients, although the significance of this finding is uncertain.
Key Words: Laryngeal mask airway, endotracheal tube, laryngeal mask, airway, pediatric, adenotonsillectomy,
tonsillectomy, adenoidectomy, laryngospasm, recovery.
Level of Evidence: 1b.
Laryngoscope, 122:429-435, 2012

INTRODUCTION between these two modalities exist and have been char-
In the United States, the number of ambulatory acterized in the literature.
surgical visits for tonsillectomies and/or adenoidectomies For outpatient procedures, the reinforced LMA
is approximately 530,000 per year. 1 As with any surgical decreases the use of nondepolarizing muscle relaxants
procedure, better outcomes, less pain, quicker recovery, and as a result may avoid possible side effects, such as
less need for postoperative pain medication, and a safer, prolonged muscle paralysis or the need for reversal
shorter surgery time are ultimate goals. Use of the rein- agents such as atropine, glycopyrrolate, or neostigmine.
forced laryngeal mask airway (LMA) and endotracheal Other advantages of the LMA include avoidance of stim-
intubation (ETT) are both accepted standards of care ulation of the larynx and vocal cords, which reduces
used to ensure adequate ventilation during a variety of cardiovascular and respiratory reflexes, 3,4 obviation of
surgical procedures.2 However, numerous differences the need for laryngoscopy, elimination of risks of endo-
bronchial or esophageal intubation, decreased use of
From the MacNeal Hospital ( D.I.S.), Berwyn, Illinois; and Henry intraoperative fentanyl,5 and improvement in various
Ford Clinic (H.C.), Detroit, Michigan, Advocate Health Care ( D.V.), Chicago, postoperative outcome parameters, such as sore
Illinois, Division of Pediatric Otolaryngology ( D.L.W.), Lutheran General
Childrens Hospital (K.S., M.L., Y.A.), Park Ridge, Illinois, U.S.A. throat,5,6 cough,3,4,6-9 desaturation,4,8,9 bronchospasm,3
Editors Note: This Manuscript was accepted for publication postoperative nausea, 5 laryngospasm, 3,6,8,9 pain,7 stri-
October 24, 2011. dor,3,7,9 and hoarse voice.6 Some studies have also
Presented as a poster at the American Society of Pediatric Otolar- suggested lower cost,5 reported decreases in intraopera-
yngology Annual Meeting, Chicago, Illinois, U.S.A., April 28-May 1,
2011; and at the Lutheran General Research Consortium, Park Ridge, tive anesthetic requirements,10 and shown decreased
Illinois, U.S.A., May 5, 2011. time required in the operating room, 7 during recovery,5
Thirty LMA Flexible reinforced laryngeal mask airways were pro- during intubation,4 and during extubation.9,11
vided by LMA North America (San Diego, CA). The authors have no
other funding, financial relationships, or conflicts of interest to disclose. Disadvantages of the LMA have also been reported,
Send correspondence to David L. Walner, MD, Lutheran General including trouble visualizing the surgical field, as well
Childrens Hospital, Division of Pediatric Otolaryngology, 1675 Dempster as leaking or kinking, which lead to difficulty ventilat-
St., 3rd Floor, Park Ridge, IL 60068. E-mail: dwalner@comcast.net
ing, problems with oxygenation, and high rates of
DOI: 10.1002/lary.22458 abandonment of the LMA in favor of the ETT.7,11,12 An

Laryngoscope 122: February 2012 Sierpina et al.: LMA vs. ETT in Pediatric Adenotonsillectomy
429
TABLE I. suspending the mouth gag from a Mayo stand. All tonsillecto-
Pain and Safety Comparisons for Endotracheal Tube Cuffed mies were done with coblation, and all adenoidectomies were
Versus Endotracheal Tube Uncuffed. done with a microdebrider followed by suction electrocautery for
t Test Test hemostasis. Adenotonsillectomies were all performed with cobla-
or v2 Statistic P Value tion alone, and no local anesthetic was used for any case.
A standard anesthesia protocol was used for all patients.
Surgery duration t 0.682 .499
The preoperative protocol included 0.3 mg/kg of midazolam, and
Anesthesia induction to surgery end t 1.033 .307 no preoperative Tylenol was given. During the surgery, no ni-
Anesthesia induction to OR exit t 1.238 .222 trous oxide was used; only sevoflurane, oxygen, or air was used
Phase I pain t 0.378 .707 for maintenance. Other intraoperative medications included
Phase II pain t 1.054 .297 dexamethasone 0.5 mg/kg to maximum 10 mg, ondansetron 0.1
mg/kg to maximum 4 mg, fentanyl 0.5 to 1 lg/kg, and at least
24-hour pain t 0.161 .872
20 mL/kg of fluids. Patients either underwent tonsillectomy, ad-
Laryngospasm v2 None* enoidectomy, adenotonsillectomy, tonsillectomy with
Phase I trouble ventilating v2 None* myringotomy and tube placement, adenotonsillectomy with
from the anesthesia form myringotomy and tube placement, or adenoidectomy with myr-
Phase I breathing problems v2 0.549 .588 ingotomy and tube placement.
Phase I desaturations v2 3.793 .285 Surveys were given to the anesthesiologist, otolaryngolo-
gist, phase I recovery nursing staff, and phase II recovery
Bonferroni corrected a .006. nursing staff, and an additional phone survey was completed 24
*No incidence of target variable.
OR operating room. hours following surgery by phase II nursing staff. Blinding was
limited to nursing staff in recovery phases and to phone sur-
veyors. Data analysis was performed using SPSS 18 (SPSS Inc.,
increased incidence of laryngospasm has also been Chicago, IL). First, to assess the degree of homogeneity between
observed.13 patients with cuffed versus uncuffed ETTs and the feasibility of
Although the literature is replete with examples of combining these groups for later tests, an independent samples
studies comparing the LMA and the ETT, few exist that t test was performed on 10 variables relating to safety and sur-
focus primarily on their use in pediatric adenotonsillec- gery duration (Table I). Next, LMA subjects were compared to
tomy. The goal of this study was to contribute to our ETT subjects using v2 for dichotomous and categorical data and
current understanding of the differences between these air- analysis of variance (ANOVA) for continuous data. There were
36 variables analyzed describing safety, surgery duration, com-
way devices in general, and to more specifically
plications, and patient comfort during, immediately after, and
understand how the two compare in pediatric adenotonsil-
24 hours after the surgery. Methods of ventilation including
lectomy with respect to multiple safety and patient comfort spontaneous, controlled, and assisted were recorded as well.
variables. We hypothesized that many of the observations Finally, to compare intubation methods in groups of patients
made in other patient populations will be borne out by this with similar surgery types, LMA subjects whose surgery
study, namely that the LMA is a safe and well-tolerated de- included tonsillectomy were compared to ETT subjects whose
vice that can be used as an alternative to the ETT in surgery included tonsillectomy, and LMA subjects whose sur-
children undergoing adenotonsillectomy. gery did not include tonsillectomy were compared to ETT
subjects whose surgery did not include tonsillectomy. The same
36 variables were analyzed using v2 for categorical data and
ANOVA for continuous data (Tables I-V).
MATERIALS AND METHODS The Bonferroni correction for multiple comparisons was
After receiving institutional review board approval and applied to each group of tests. Statistically significant values at a
informed consent, a total of 117 pediatric patients from a hospi- .05 as well as at the determined Bonferroni corrections are
tal and an ambulatory surgery center scheduled for airway identified to provide the most stringent tests possible.
surgery from December 2009 to March 2011 were randomized
by birth date to undergo intubation using either the LMA or
ETT; patients with birth dates in odd-numbered months
received the LMA, and those with birth dates in even-numbered RESULTS
months received the ETT. Approval was given for patients Sample demographics are displayed in Table VI by
between the ages of 2 and 18 years, and all had an American ETT and LMA surgery groups. Both groups were similar
Society of Anesthesiologists (ASA) score of I or II. Two patients on all variables reported. The mean age for the ETT sur-
were excluded from the final analysis. One patient was random- gery group was 5.88 years (SD, 2.33; range, 2-13 years),
ized to the LMA group and was found to have an upper and the mean age for the LMA surgery group was 5.02
respiratory tract infection (URI) with copious airway secretions years (SD, 2.31; range, 2-13 years). The male to female
on the day of surgery. The other was randomized to the ETT
ratio in both groups was 3:2, as was the ratio of ASA I
group and suffered an episode of laryngospasm prior to tube
insertion. The final analysis included 50 patients in the ETT to ASA II patients, and the site distribution was approx-
group, 27 cuffed ETTs and 23 uncuffed, and 65 patients in the imately 2:1 in both groups. Surgery types were equally
LMA group. distributed in both groups, with 54% ETT tonsillecto-
Anesthesia was provided by attending pediatric anesthesi- mies compared to 52% LMA tonsillectomies, and 46%
ologists who were with the patients for the entirety of the ETT nontonsillectomies compared to 48% ETT nontonsil-
surgeries, and an attending pediatric otolaryngologist per- lectomies. No adverse outcomes were seen in either
formed all of the operations. A McIVOR mouth gag was slid in group.
over the flexible LMA, with Surgilube used occasionally. If the Surgery variables were collected as three groups:
patient was not ventilating well, adjustments were made after ETT cuffed, ETT uncuffed, and LMA; however, the

Laryngoscope 122: February 2012 Sierpina et al.: LMA vs. ETT in Pediatric Adenotonsillectomy
430
primary focus of this study was to compare ETT versus fentanyl dose, production, desaturation, and hoarse
LMA on relevant study variables. To assess the degree voice/stridor for all three comparison groups. The differ-
of homogeneity between patients with cuffed versus ence between desaturation for the ETT nontonsillectomy
uncuffed ETTs and the feasibility of combining these versus LMA nontonsillectomy surgeries approached sig-
groups for later tests, 10 variables relating to safety and nificance when compared to the .05 criteria but failed to
surgery duration were compared. There were no statisti- approach the Bonferroni corrected criteria of .002 (v2
cally significant differences between the groups (Table 5.823, P .054). In the ETT nontonsillectomy group,
I); therefore, ETT cuffed and ETT uncuffed were com- 82% of the patients had no observed desaturations, 9%
bined for the remainder of the analysis. had one observed desaturation, and 9% had two
Next, patient safety and comfort variables as well observed desaturations, whereas no subjects in the LMA
as duration variables were compared for ETT versus nontonsillectomy group experienced a desaturation
LMA during the anesthesia, surgery, immediately after event.
surgery, and 24 hours after surgery. Analysis was per- Results for phase II recovery and 24 hours following
formed for all ETT procedures versus all LMA surgeries, surgery were similar to those for phase I recovery
for ETT tonsillectomy versus LMA tonsillectomy sur- (Tables IV and V). Coughing, hoarse voice, and stridor
geries, and for ETT nontonsillectomy versus LMA immediately after surgery were higher in the ETT non-
nontonsillectomy surgeries. Overall, ETT and LMA were tonsillectomy group versus LMA nontonsillectomy group
comparable with few statistically significant differences (coughing: 35% in ETT, 7% in LMA; hoarse voice/stridor:
(Tables II-V). 17% in ETT, 0% in LMA). Although both of these differ-
When comparing all ETT surgeries to all LMA sur- ences were statistically significant when compared to
geries during surgery, only two of the 11 safety, comfort, the .05 criteria, both failed to approach the Bonferroni
and duration variables were statistically significant at corrected criteria of .002 (coughing: v2 7.024, P .012;
the Bonferroni correction level or at the .05 level (Table hoarse voice/stridor: v 2 5.823, P .028). No other com-
II). Subjects on whom the ETT was used were found to parisons on phase II recovery variables were statistically
cough or gag more during the anesthesia phase than significant: duration, vomiting, pain, breathing prob-
subjects in whom the LMA was used (48% for ETT vs. lems, production, bleeding severity, and oral fluid
20% for LMA; v2 10.153, P .002). This difference intake. All 24-hour postsurgery variables were statisti-
was also statistically significant for ETT nontonsillec- cally insignificant for all ETT versus LMA surgeries,
tomy versus LMA nontonsillectomy surgeries (48% for ETT tonsillectomy versus LMA tonsillectomy surgeries,
ETT vs. 3% for LMA; v 2 15.196, P .000), but there and ETT nontonsillectomy versus LMA nontonsillectomy
was no statistical difference for coughing or gagging for surgeries when applying the Bonferroni correction. One
ETT tonsillectomy versus LMA tonsillectomy surgeries. variable, noisy breathing, was statistically significant for
The method of ventilation was significantly differ- all ETT versus LMA surgeries when compared to the .05
ent for all ETT surgeries versus all LMA surgeries (ETT criteria (12% for ETT vs. 2% for LMA; v2 5.411, P
spontaneous 57%, assisted 16%, controlled 27% vs. LMA .042). Hoarseness, coughing, production, gagging, vomit-
spontaneous 84%, assisted 16%, controlled 0%: v2 ing, pain, swallowing soft foods, and drinking were not
19.493, P .000), and for ETT tonsillectomy versus statistically significant at either a criterion.
LMA tonsillectomy (ETT spontaneous 58%, assisted
15%, controlled 27% vs. LMA spontaneous 88%, assisted
12%, controlled 0%: v 2 11.131, P .000) at the Bonfer- DISCUSSION
roni correction level. Although ventilation type for ETT The LMA was introduced into clinical practice in
nontonsillectomy versus LMA nontonsillectomy was sig- 1988 and was first implemented for adenotonsillectomy
nificant at the .05 level (ETT spontaneous 57%, assisted in 1993.2,4 Despite the documentation of numerous
17%, controlled 26% vs. LMA spontaneous 79%, assisted advantages of LMA use in this and other settings,
21%, controlled 0%: v 2 8.6, P .014), this difference widespread adoption of the device for pediatric adenoton-
failed to achieve statistical significance at the Bonferroni sillectomy has been stalled by concerns over limitation
correction level of .006. Additionally, surgery time to of surgical access, aspiration, laryngospasm, and
operating room (OR) exit approached significance at the obstruction of the tube caused by kinking, which may
.05 level for all surgeries combined and for ETT nonton- lead to difficulty ventilating and decreased oxygenation.
sillectomy versus LMA nontonsillectomy surgeries. The The results of the current study add to a growing body
mean differences in surgery time were approximately 90 of evidence supporting LMA use in general, and to a
seconds and 2 minutes longer, respectively, for ETT than small number of reports supporting LMA use in pediat-
LMA. All three comparison groups were similar for the ric adenotonsillectomy.
other duration variables, the number of placement There is impressive agreement in the literature on
attempts and gap adjustments, occurrence of laryngo- the point that postoperatively, the LMA is associated
spasm or ventilation trouble, and ease of wake-up. with increased patient comfort in studies comparing it to
In general, the three comparison groupings were the ETT. This is reflected in multiple independent meas-
very similar for the 10 safety, comfort, and duration var- urements as outlined above. Decrease in cough is a
iables during phase I recovery (Table III). There were no common finding in such studies,3,4,5,7-9 as was the case
statistically significant differences for surgery duration, with our data set. More specifically, we found that
coughing, gagging, vomiting, pain, breathing problems, coughing or gagging was significantly increased to the

Laryngoscope 122: February 2012 Sierpina et al.: LMA vs. ETT in Pediatric Adenotonsillectomy
431
TABLE II.
Comparisons for Endotracheal Tube Versus Laryngeal Mask Airway During Surgery.
All Surgeries Surgeries Surgeries Not
Combined, Test Including Tonsillectomy, Including Tonsillectomy,
t Test or v2 Statistic (P Value) Test Statistic (P Value) Test Statistic (P Value)

No. of placement attempts t 0.159 (.874) 1.278 (.206) 0.857 (.395)


Trouble ventilating v2 1.566 (.504) None* 1.541 (.502)
Ventilation type v2 19.493 (.000) 11.131 (.004) 8.6 (.014)
Laryngospasm v2 1.566 (.504) 1.642 (.498) None*
Coughing or gagging v2 10.153 (.002) 1.028 (.432) 15.196 (.000)
Ease of wake up v2 2.724 (.111) 0.856 (.422) 4.281 (.071)
Surgery duration t .128 (.898) 1.140 (.259) 0.858 (.395)
Anesthesia-surgery end time t 0.412 (.681) 1.272 (.208) 1.114 (.270)
Anesthesia to OR exit t 0.823 (.412) 0.981 (.330) 1.465 (.149)
Surgery end to OR exit t 1.913 (.058) 0.729 (.469) 1.98 (.053)
No. of gag adjustments t 1.744 (.084) 0.385 (.702) 1.751 (.086)
Bonferroni corrected a .006.
*No incidence of target variable.

Significant at Bonferroni corrected a .006; endotracheal tube showed more coughing/gagging and less spontaneous ventilation.

Significant at a .05; endotracheal tube showed increased controlled ventilation.

Bonferroni a level in the anesthesia phase in ETT


patients whose adenoids, but not tonsils, were operated throat associated with use of the ETT.6 These findings
on. While in recovery and at 24 hours after surgery this are logical in light of the fact that the LMA avoids con-
level of significance was not observed. We also found an tact with the larynx, vocal cords, and trachea, thus
increase in cough, hoarse voice, and stridor in phase II decreasing irritation and trauma to the airway. More-
recovery in ETT patients not undergoing tonsillectomy, over, a decrease in symptoms of airway irritation with
and an increase in noisy breathing at 24 hours following the use of the LMA suggests that concerns over laryn-
surgery when the ETT was used, comparing all LMA to geal soiling with blood and secretions through leaks in
all ETT patients. Although these findings were signifi- the seal the LMA forms with the laryngeal inlet may be
cant at the .05 level, they failed to reach significance at unfounded. Peng et al. compared the LMA and the ETT
the Bonferroni a level used to correct for multiple com- in 132 children undergoing adenotonsillectomy, and
parisons. Webster et al. compared the LMA and the ETT found soiling of the laryngeal inlet in only one of 48
in pediatric adenotonsillectomy and also found an LMA patients,11 and Webster et al. found no laryngeal
increase in stridor in ETT patients. 4 In that study, ade- soiling or blood on the laryngeal surface of the LMA in
noidectomy and adenotonsillectomy patients were their series of 55 children.4
grouped together for analysis. A systematic review by Despite various reports in small patient populations
Yu et al. examined 29 randomized control trials (RCTs) (<150) describing high rates of conversion (8.1%-16.7%)
comparing ETT and LMA in general anesthesia and from LMA to ETT due to obstruction from kinking and
found an increase in hoarse voice, coughing, and sore trouble visualizing the surgical field,4,7,11,12 our analysis
of 65 cases of LMA use did not result in a single
TABLE III.
Comparisons for Endotracheal Tube Versus Laryngeal Mask Airway During Phase I Recovery.
Surgeries Including Surgeries Not
All Surgeries Combined, Tonsillectomy, Test Including Tonsillectomy,
2
t Test or v Test Statistic (P Value) Statistic (P Value) Test Statistic (P Value)

Duration t 0.501 (.617) 0.320 (.750) 0.385 (.702)


Coughing v2 3.550 (.169) 2.209 (.331) 1.789 (.409)
Gagging v2 1.385 (.239) 1.354 (.392) None*
Vomiting None* None* None*
Pain score t 0.470 (.639) 0.793 (.432) 1.740 (.880)
Breathing problems v2 .810 (.510) 0.789 (.448) 0.111 (1.000)
Fentanyl doses v2 2.829 (.587) 2.931 (.402) 5.775 (.217)
Production v2 1.006 (.800) 1.466 (.690) 2.878 (.237)
Desaturation v2 1.484 (.686) 1.840 (.606) 5.823 (.054)
Hoarse voice/stridor v2 4.238 (.120) 1.880 (.391) 2.523 (.283)
Bonferroni corrected a .002.
*No incidence of target variable.

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432
TABLE IV.
Comparisons for Endotracheal Tube Versus Laryngeal Mask Airway During Phase II Recovery.
All Surgeries Surgeries Surgeries Not
Combined, Test Including Tonsillectomy, Including Tonsillectomy,
t Test or v2 Statistic (P Value) Test Statistic (P Value) Test Statistic (P Value)

Duration t 0.296 (.768) 0.598 (.552) 0.024 (.981)


Coughing v2 1.952 (.162) 0.339 (.740) 7.024 (.012)*
Vomiting v2 1.217 (.327) 0.547 (.647) 0.683 (.640)
Pain score t 0.733 (.465) 0.263 (.794) 1.709 (.093)
Breathing problems None None None
2
Production v 0.647 (.412) 0.807 (1.000) 2.799 (.177)
Bleeding severity v2 1.942 (.379) 0.644 (.623) 1.460 (.482)
Oral fluid intake v2 0.561 (.755) 0.340 (.844) 0.888 (.642)
Hoarse voice/stridor v2 2.932 (.124) 0.123 (1.000) 5.823 (.028)*
Bonferroni corrected a .002.
*Significant at a .05; endotracheal tube subjects experienced more coughing, hoarse voice, and stridor than laryngeal mask airway subjects.

No incidence of target variable.

instance of conversion, although there were two cases of abandoned in five patients, all of which occurred during
difficult ventilation that resolved with gag adjustment. the first 15 patients of the trial. Three of these patients
Our findings are in agreement with larger studies such showed signs of obstruction on opening of the Boyle-
as that performed by Gravningsbra ten et al., in which Davis gag, a problem that was ameliorated later in the
1,126 children underwent adenotonsillectomy with an study with increased experience and anesthesia use.
LMA in place, and conversion occurred in only seven This led the authors to conclude that the likeliest cause
patients (0.6%) due to six cases of air leak around the of airway obstruction on opening the B-D gag with the
LMA and one case of atelectasis. 14 Joshi et al. similarly LMA was inadequate anaesthesia with reflex laryngeal
showed a 1% conversion rate in 341 adult outpatients closure.4 The other conversions occurred due to a leak
but did not report reasons for LMA abandonment, 5 and around the LMA, and due to bronchospasm that was
Verghese and Brimacombe reported a 0.19% conversion likely related to a recent URI.
rate in 11,910 adults and children due to leaks and Reports regarding conversion due to difficulty with
placement failure.15 These numbers compare to Rose surgical field visualization are similarly disparate, with an
and Cohens report of 0.3% ETT failure in a study of apparently equal number of studies in both adults and
18,500 patients, and in that same study an LMA failure children reporting no difficulty with access3,4,14 and access
rate of 4.7% is given for 634 patients, with reasons for troubles extreme enough to require abandonment of the LMA
failure not reported.16 Considering our experience and in favor of the ETT.6,11,12 Additionally, Hern et al. found that
taking the results of prior studies into account with the weight of excised tonsillar tissue was less in patients
greater weight on studies with larger patient popula- where the LMA was used. In our experience, use of the
tions, it is reasonable to conclude that high rates of LMA with a McIVOR gag offered an excellent view of the
conversion associated with kinking may be a result of surgical field.
technique rather than the fault of the LMA per se. Web- It has been noted in prior studies that LMA use is
ster et al. pointed out that in their series the LMA was associated with an increase in spontaneous ventilation
TABLE V.
Comparisons for Endotracheal Tube Versus Laryngeal Mask Airway 24 Hours After Surgery.
All Surgeries Surgeries Including Surgeries Not
Combined, Test Tonsillectomy, Test Including Tonsillectomy,
2
T Test or v Statistic (P Value) Statistic (P Value) Test Statistic (P Value)

Hoarseness v2 1.143 (.298) 0.108 (.786) 1.563 (.322)


Coughing v2 1.643 (.440) 1.707 (.426) 0.541 (.560)
Production v2 0.125 (1.000) 1.300 (.371) 0.753 (.569)
Gagging v2 0.001 (1.000) 0.040 (1.000) 0.047 (1.000)
Vomiting v2 0.125 (1.000) 2.054 (.214) 2.799 (.177)
Pain t 0.936 (.352) 0.470 (.640) 1.324 (.191)
Noisy breathing v2 5.411 (.042)* 2.820 (.161) 2.799 (.177)
Swallowing soft foods v2 0.210 (.900) 0.321 (.852) 0.000 (1.000)
Drinking v2 0.281 (.869) 0.164 (.921) 1.983 (.371)
Bonferroni corrected a .002.
*Significant at a .05; endotracheal tube subjects experienced more noisy breathing than laryngeal mask airway subjects.

Laryngoscope 122: February 2012 Sierpina et al.: LMA vs. ETT in Pediatric Adenotonsillectomy
TABLE VI. cases of laryngospasm in children under 18 years old
Sample Characteristics. conducted by Flick et al. identified LMA use as an inde-
ETT, n 50 LMA, n 65 pendent risk factor for laryngospasm in general
anesthesia.13 In balance, and taking our experience into
Age, yr, mean (SD) 5.88 (2.33) 5.02 (2.31)
consideration, it appears that the weight of the evidence
Gender, no. (%)
suggests against an increased risk of laryngospasm with
Male 30 (60) 38 (59) use of the LMA.
Female 20 (40) 27 (41) Given the current prevalence of pediatric adenoton-
Site, no. (%) sillectomy,1 any decrease in the cost of this procedure
Hospital surgery center 33 (66) 44 (67) would represent a large total cost savings. To this end,
Ambulatory surgery center 17 (34) 21 (32) the effects of LMA use on time spent in the OR and in
Surgeries including tonsillectomy 27 (54) 34 (52) recovery have been investigated by this and other
Surgeries not including tonsillectomy 23 (46) 31 (48) reports. Doksrd et al. showed in a population of 134
ASA, no. (%) children undergoing adenotonsillectomy that the
patients in the LMA group spent significantly less time
I 30 (60) 38 (59)
in the OR after surgery (4.2 minutes), but total OR time
II 20 (40) 27 (41)
failed to reach significance. 7 The authors pointed out
ETT endotracheal tube, LMA laryngeal mask airway; SD that in their study patients were moved to recovery with
standard deviation; ASA American Society of Anesthesiologists. the LMA still in place. This finding was replicated by
Webster et al. in their 1999 study on intranasal surgery
compared to ETT use.4,17 Webster et al. reported that in in adults and children, which reported a decreased time
addition to decreased use of assisted ventilation, when from discontinuation of anesthesia to OR exit in LMA
assisted ventilation was used in LMA patients it was of patients compared to ETT patients who were extubated
shorter duration.4 In our analysis, this effect reached awake when the LMA was removed in recovery. 9 In their
significance at the Bonferroni a level of .006 for all recent study of 131 children undergoing adenotonsillec-
surgeries combined and for surgeries including tonsillec- tomy, Peng et al. also found a decreased time between
tomy, and reached significance at the a .05 level for surgery end and extubation in the LMA group, but
surgeries not including tonsillectomy. Our anesthesiolo- found no significant difference in total anesthesia time,
gists routinely use assisted ventilation in patients with in their judgment owing to either time devoted to LMA
an ETT to overcome the resistance of the tube. Further- tube adjustments or to fiberoptic laryngoscopy performed
more, assisted ventilation is often avoided in LMA in the LMA group.11 Joshi et al. failed to note a signifi-
patients due to concerns over gastric insufflation, aspira- cant difference between the LMA and the ETT with
tion, and nausea, although Verghese and Brimacombe respect to time from surgery end to device removal in a
found that there was no significant reduction in critical study of 381 adult patients undergoing elective ambula-
incidents in LMA patients when spontaneous ventilation tory surgery.5 Our findings are in agreement with Joshi
was used, including regurgitation, vomiting, aspiration et al., although the time between surgery end and OR
of gastric contents, bronchospasm, laryngospasm, gastric exit was shorter in the LMA group and approached sig-
dilation, hypotension, arrhythmias, or arrest. 15 Sponta- nificance for all surgeries combined. This result may
neous ventilation has not been shown to decrease have reached significance had we brought patients to re-
anesthetic requirements in these patients, 18 but it is covery with the LMA in place like Doksrd and Webster.
possible that emergence from anesthesia is expedited in However, whether or not this would have translated to a
patients breathing on their own compared to those de- significant reduction in OR time and ultimately cost sav-
pendent on the ventilator. Beyond this observation, the ings is doubtful considering that an actual reduction in
clinical significance of increased use of spontaneous ven- OR time has not been shown in any study to date.
tilation is uncertain. Our study also failed to demonstrate significant
In our series, two patients in the LMA group expe- reductions in time spent in recovery, which agrees with
rienced brief episodes of laryngospasm on removal of the Peng et al.11 Although Joshi did report less time in the
LMA that were easily controlled using face mask venti- PACU and a decreased time to ambulation, this did not
lation for <1 minute with no sequelae. There were no translate to home readiness.5 The differences between
episodes of laryngospasm in the ETT group. However, these results may be because a standardized anesthesia
this difference failed to reach statistical significance. protocol was put in place in our study and that of Peng
Most RCTs conducted to date comparing the ETT to the et al., whereas Joshi et al. used no standardization, lead-
LMA in adenotonsillectomy or for use in other surgery ing to an increase in fentanyl usage in the ETT group.
types have shown either an increased incidence of lar- Our investigation was limited in several ways.
yngospasm when ETTs are used,3,6,8,9 or no difference First, our findings cannot be applied to patients with
was detected.4,11,12 Moreover, the systematic review by abnormal airways, because all of our enrolled subjects
Yu et al. outlined above included seven studies that were ASA category I or II. Second, the homogeneity of
dealt with this topic. Their analysis showed an increased the groups under study was limited. Various surgery
incidence of laryngospasm in surgeries where the ETT types were included, which we attempted to address by
was used compared to those in which the LMA was categorizing surgeries involving tonsillectomy and those
used. However, a 2:1 case-control study including 130 not involving tonsillectomy. In addition, both cuffed and

Laryngoscope 122: February 2012 Sierpina et al.: LMA vs. ETT in Pediatric Adenotonsillectomy
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