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cLMA and PLMA for laparoscopic surgery

Bath, England

To the Editor:

I wish to comment on Dr. Cooper’s editorial regarding the use of laryngeal mask airways (LMA) for laparoscopic surgery.¹

Firstly, avoiding a LMA will require tracheal intubation. This will lead to a 1.8% likelihood of difficult intubation, 0.3% failed intubation, 0.011% failed intubation with difficult ventilation and associated complications.²

Tracheal intubation prevents aspiration, while the tube is in the trachea. Warner et al. studied 67 cases of aspiration during 215,488 operations.³ Aspiration incidence (0.11% emergency and 0.025% elective) was higher than for the classic LMA (cLMA; 0.009%).⁴ Aspirations occurred during laryngoscopy in 32.9% and during extubation in 35.9%. As these are essential components of anesthesia, the assumption that a tracheal tube is safer than the LMA is open to debate.

The second point is that Dr. Cooper does not distinguish between the cLMA and ProSeal LMA (PLMA). The PLMA is designed to separate the gastrointestinal and respiratory tracts and improve mechanical ventilation. There is increasing evidence these aims are achieved.⁵

Dr. Cooper hopes that evidence of safety will be available from randomized controlled trials (RCT). Detecting a 50% reduction in aspiration between cLMA and PLMA would require approximately 1.3 million patients per group.

Arguments therefore exist that, for laparoscopic surgery, each of the available airways is the best choice. No RCT will adequately inform which is best for a given group of patients. Even if it did this will not ensure that a specific device is the best choice for an individual patient presenting for anesthesia. Anesthesiologists must continue to analyze the currently limited ‘best available evidence’ and make their own balanced decision.

References

1 Cooper RM. The LMA, laparoscopic surgery and the obese patient – can vs should (Editorial). Can J Anesth 2003; 50: 5–10.[Free Full Text]

2 Rose DK, Cohen MM. The airway: problems and predictions in 18,500 patients. Can J Anaesth 1994; 41: 372–83.[Abstract/Free Full Text]

3 Warner MA, Warner ME, Weber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology 1993; 78: 56–62.[Medline]

4 Sidaras G, Hunter JM. Is it safe to artificially ventilate a paralysed patient through the laryngeal mask? The jury is still out. Br J Anaesth 2001; 86: 749–53.[Free Full Text]

5 Cook TM, Nolan JP, Verghese C, et al. Randomized crossover comparison of the proseal with the classic laryngeal mask airway in unparalysed anaesthetized patients. Br J Anaesth 2002; 88: 527–33.[Abstract/Free Full Text]

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REPLY

Richard M. Cooper
CJA 2003 50: 966. [Full Text]  

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