The laryngeal mask airway in infants and children

To compare the effectiveness of various laryngeal mask airway (LMA) sizes and their performance during positive pressure ventilation (PPV) in paralyzed pediatric patients. Pediatric patients (n = 158), < 30 kg, ASA 1 or 2 were studied. After paralysis, an LMA of the recommended size was inserted and connected to a volume ventilator. Fibreoptic bronchoscopy (FOB) was performed and graded: 1, larynx only seen; 2, larynx and epiglottis posterior surface seen; 3, larynx, and epiglottis tip or anterior surface seen--visual obstruction of epiglottis to larynx: < 50%; 4, epiglottis down-folded, and its anterior surface seen--visual obstruction of epiglottis to larynx: > 50%; 5, epiglottis down-folded and larynx not seen directly. Inspiratory and expiratory tidal volumes (V(T)), and airway pressure were measured by a pneumo-tachometer, and the fraction of leakage (F(L)) was calculated. In 79 cases, LMA was used for airway maintenance throughout surgery. Successful LMA placement was achieved in 98% of cases: three failures were due to gastric insufflation. For LMA # 1, 1.5, 2, and 2.5, FOB grades [median (range)] were 3(1-5), 3(1-5), 1(1-5) and 1(1-3) respectively. In smaller LMAs, the cuff more frequently enclosed the epiglottis (P < .001). F(L) of LMA # 1 was higher than those of LMA # 1.5 and LMA # 2.5 (P < .05), and F(L) of LMA # 2 was higher than that of LMA # 2.5 (P < .05). In the 79 patients, the number of patients experiencing complications decreased as LMA size increased (P < .05). Use of the LMA in smaller children results in more airway obstruction, higher ventilatory pressures, larger inspiratory leak, and more complications than in older children.