PEDIATRIC

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WILLIAM J. GREELEY

Use of the laryngeal Mask Airway in Children with Upper Respiratory Tract Infections: A Comparison with Endotracheal Intubation
Alan R. Tait, PhD, Uma A. Pandit, MD, Terri Voepel-Lewis, Hamish M. Munro, MD, FRCA, and Shobha Malviya, MD
Department of Anesthesiology, University of Michigan Medical BSN, MS,

Center, Ann Arbor,

Michigan

Several studies suggest that placement of an endotracheal tube (ETT) in a child with an upper respiratory infection (URI) increases the risk of complications. However, the development of the laryngeal mask airway (LMA) has provided anesthesiologists with an alternative means of airway management. This study was therefore designed to evaluate the use of the LMA in children with URIS and to compare it with the ETT. The study sample consisted of 82 pediatric patients (3 mo to 16 yr of age) who presented for elective surgery with an URI. Patients with URIS were randomly allocated to receive either an ETT (n = 41) or a LMA (n = 41) and were followed for the appearance and severity of any perioperative complications. The two groups were similar with respect to age, gender, anesthesia and surgery times, number of attempts at tube placement, and presenting URI symptoms. There were no differences between groups in the incidence of cough, breathholding, excessive secretions, or arrhythmias. Although one patient in the ETT group required a muscle relaxant for laryngospasm, the overall incidence of laryngospasm was similar between the two groups. There was, however, a significantly greater incidence of

mild bronchospasm in the ETT group compared with the LMA group (12.2% vs 0%, P < 0.05). The incidence of major arterial oxygen desaturation events (Spo, <90%) during placement of the airway device was also significantly increased in the ETT group (12.5% vs 0%, P < 0.05). Furthermore, the total number of all episodes of respiratory complications, i.e., breath-holding, laryngospasm, bronchospasm, and major oxygen desaturation, was significantly greater in the ETT group (35 vs 19, P < 0.05). Despite this, all respiratory complications were easily managed, and there were no adverse sequelae. Although the risks associated with anesthetizing a child with an URI remain controversial, results from this study suggest that the LMA offers a suitable alternative to the ETT for use in children with URIS. Implications: This study compares the use of the laryngeal mask airway with the endotracheal tube for airway management in children with upper respiratory infections. Results suggest that if the decision is made to proceed with anesthesia for the child with an upper respiratory infection, then the laryngeal mask airway provides a suitable alternative to the endotracheal tube. (Anesth Analg 1998;86:706-11)

he issue of whether to proceed with anesthesia for the child who presents for elective surgery with an upper respiratory infection (URI) has been a source of debate for many years. However, if the decision is made to proceed with anesthesia, it is important to establish a secure airway with minimal stimulation. Although the use of a face mask (FM) for a child with an URI may be associated with lower risk (l), it may not be appropriate for certain surgical procedures. Until recently, the endotracheal tube (ETT) has been the only alternative to a FM; however, some studies suggest that its placement in a child with

Accepted for publication December 16, 1997. Address correspondence and reprint requests to Alan R. Tait, PhD, Department of Anesthesiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI 48109. 706

a potentially irritable airway increases the risk of perioperative respiratory complications, including cough, laryngospasm, and bronchospasm (1,2). Since its commercial introduction in 1988, the laryngeal mask airway (LMA) has proven to be a safe and effective technique for airway management in both adults and children (3,4). The apparent lack of laryngeal stimulation makes the LMA a potentially attractive alternative for airway management in children with URIS. In addition, reports suggest that the incidence of postoperative sore throat associated with the placement of a LMA is much less than that associated with an ETT (5,6). This study was designed to determine the incidence of perioperative complications in children with URIS and to evaluate the efficacy and safety of the LMA as an alternative to the ETT in this population of patients.
01998 by the International Anesthesia Research Society 0003-2999/98/$5.00

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We hypothesized that the incidence of perioperative respiratory complications associated with the placement of a LMA in children with acute uncomplicated URIS is less than that associated with an ETT.

Methods
This study was approved by our institutional review board, and informed consent was obtained from the parents or legal guardians of each patient. The study sample included ASA physical status I or II pediatric patients between the ages of 3 mo and 16 yr of age who presented for elective outpatient surgery with an URI. Patients who underwent procedures that could be performed using either an ETT or a LMA were included. Patients were excluded if they presented with any evidence of lower respiratory tract involvement or if the anesthesiologist determined that proceeding with surgery would be hazardous to the patient. Other exclusion criteria included ASA physical status III or higher, abnormal airway anatomy, children with full stomachs, procedures requiring muscle relaxation or IV induction, and surgery involving the upper airways. Patients with co-existing pulmonary disease, asthma, or cardiac disease were also excluded. On the day of surgery, detailed information regarding the presence of an URI was sought. Information was recorded with respect to the patients URI symptoms, their severity, and the phase (i.e., onset, peak, or resolution) of the infection. The diagnosis of an URI was based on the childs presenting symptoms and required confirmation by a parent. Children diagnosed with URIS were randomly allocated (using tables of random numbers) to receive either a LMA or an ETT. In both groups, anesthesia was induced with N,O/O,/halothane, and the LMA or ETT was placed using standard techniques. Muscle relaxants were not used to facilitate placement of the airway device. All patients were given 100% 0, for at least 60 s before placement of the airway device. The LMA or ETT was placed when the patient was considered unconscious enough. to tolerate airway manipulation. This was judged by clinical signs of reduced heart rate and blood pressure, jaw relaxation, central fixation of the pupils, and regular respiration. Once the LMA or ETT was in position, anesthesia was maintained with halothane or isoflurane in N,O/O,. All children were allowed to breathe spontaneously without the aid of positive pressure ventilation. Monitoring included pulse oximetry (Spa,), electrocardiography, respiratory rate, end-tidal CO,, and automated blood pressure. The LMA was removed with the cuff inflated. The depth of anesthesia at which the LMA or ETT was removed was left to the discretion of the anesthesiologist responsible for the case. Patients were observed

for the appearance of any complications such as cough, laryngospasm, bronchospasm, breath-holding, or arrhythmias at the following times: induction of anesthesia, tube placement, during surgery, during tube removal, and in the postanesthesia care unit (PACU). The occurrence of any complication was documented, and the severity scored using a previously published scale (7). Arterial oxygen desaturation was defined as minor (Spa, 90%-94% for 10 s or more) or major (Spa, ~90% for 10 s or more). Because it was not possible to blind the observers to the type of tube being used, all observations were recorded by qualified individuals who were not involved in the study. The parents of the children were contacted by telephone on the day after surgery to determine whether there were any complications, such as sore throat, nausea and vomiting, or changes in URI symptoms. In a study by Cohen et al. (l), children who had an URI and their tracheas intubated were shown to have an 11-fold increase in respiratory complications compared with children without URIS. In determining sample size, we assumed that the incidence of respiratory complications among children with URIS who have a LMA would be greater than that associated with FM anesthesia but less than with an ETT. Given this information, we believed that it would be important to detect a 50% reduction in the incidence of respiratory complications using a LMA. If we assume that the incidence of respiratory complications in children without URIS is approximately 5%, and we anticipate a 5.5-fold and 11-fold increase in respiratory complications for children with URIS receiving a LMA or an ETT, respectively, then we would need a sample size of 40 children per group (p = 20%, (Y = 5%) to detect such a difference. Parametric data were analyzed using unpaired t-tests. Nonparametric data were analyzed using 2 with Fishers exact test and, where appropriate, Wilcoxon and Mann-Whitney &tests. Data are expressed as mean Ifr SD. Significance was accepted at the 5% level (P < 0.05).

Results
Eighty-two patients were randomized to receive either a LMA (n = 41) or an ETT (n = 41). The demographics of the two groups are described in Table 1. There were no differences between the two groups with respect to age, ASA physical status, duration of anesthesia and surgery, or in the experience of the anesthesiology personnel. The number of attempts at placing either the LMA or ETT was also similar, and the duration of breath-holding during tube insertion was never more than 15 s in either group. The distribution of orthopedic, ophthalmologic, and general surgical procedures was similar between the two groups; however, significantly (P < 0.05) more urologic procedures were performed using an LMA (Table 1). The most common

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Table

1. Demographics LMA (n = 41) ETT (n = 41) 4.1 It 3.5 68/32 87.8/12.2 71.8 +- 41.3 105.8 + 45.5 1, 14 8 (19.6) 11 (26.8) 1 (2.4) 11 (26.8) 10 (24.4) (n = 38) 0 (0.0) 9 (23.7) 16 (42.1) 10 (26.3) 3 (7.9)

Age 64
Gender (M/F %) ASA physical status (I/II %) Duration of surgery (min, mean -C SD) Duration of anesthesia (min, mean 2 SD) Attempts at tube placement (median, range) Surgical service [n (%)] Urology Ophthalmology Otolaryngology General surgery Orthopedic surgery Staff [n (%)I CA-l CA-2 CA-3 CRNA Faculty
LMA *P i = laryngeal 0.05 versus mask airway, endotracheal ETT = endotracheal tube. tube.

3.7 + 3.0 61/39 80.5/19.5 60.5 t 33.9 96.1 + 42.0 1, l-3 18 11 0 6 6 (n 1 7 13 12 4 (44.0)* (26.8) (0.0) (14.6) (14.6) = 37) (2.7) (18.9) (35.1) (32.5) (10.8)

surgical procedures were cystoscopy, hypospadias repair, orchidopexy, hernia repair, strabismus correction, and orthopedic procedures. There were no differences in the prevalence of presenting symptoms (Table 2) or in the phase of the URI. The seasons in which the patients were recruited were also similar between the two groups. The presence of an URI was confirmed by all parents. The incidence of perioperative complications at each of the time points are described in Table 3. There were no differences between groups with respect to the incidence of perioperative cough, laryngospasm, or breath-holding. In addition, there were no differences in the incidence of arrhythmias, excitement, or excessive secretions. There were also no statistically significant differences in the severity of any of the complications, except for cough (rated on a 4-point scale from none to continuous), which was more persistent during the placement of the ETT (P < 0.05). Two episodes of breath-holding lasting longer than 30 s were observed (one in each group). Overall, there were seven episodes of laryngospasm (one patient had two episodes). Six of these episodes were described as partial (four in the LMA and two in the ETT group), and one required the use of a muscle relaxant (ETT group). Five patients (12.2%) in the ETT group experienced at least one episode of bronchospasm (two patients had more than one episode). Of a total of eight episodes of bronchospasm (all in the ETT group), seven were described as mild. One patient experienced wheezing on inspiration and expiration, but ventilation was maintained without undue difficulty. No bronchospasm was observed in the LMA group (P < 0.05). During tube placement, there was a significantly greater incidence of major desaturation events

Table

2. Presenting

Symptoms LMA ETT 34 22 3 18 22 12 1 (82.9) (53.7) (7.3) (43.9) (53.7) (29.3) (2.4)b

Symptoms Rhinorrhea

Nasal congestion
Sore throat Sneezing Nonproductive cough Productive cough Fever Timing of symptoms Onset Middle End

35 21 4 19 21 13 0

(85.4) (51.2) (9.8) (46.3) (51.2) (31.7) (0.0)

11 (32.4) 7 (20.6) 16 (47.0)

9 (26.5) 7 (20.6) 18 (52.9)

tube. was not collected

Data are n (%). Lh4A = laryngeal mask airway, ETT = endotracheal * Numbers do not add up to 82 because this information on the first 14 patients. b Fever was defined as temperature of 38C.

(Spo, <90%) in the ETT group (12.5% vs 0%, P < 0.05). Furthermore, the total number of all episodes of respiratory complications, i.e., breath-holding, laryngospasm, bronchospasm, and major oxygen desaturation, was significantly greater in the ETT group (35 vs 19, P < 0.05). Despite this, all respiratory events were easily managed, and there were no adverse sequelae. One patient in the ETT group who had been discharged in satisfactory condition subsequently developed postintubation croup. The child was seen in the pediatric urgent care clinic but did not require treatment or readmission to the hospital. Postoperatively, there was a slightly higher incidence of vomiting in the ETT group compared with the LMA group (41.5% vs 25%), and twice the incidence of sore throat (25.6% vs 13.5% respectively).

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Table

3. Incidence

of Perioperative Induction

Complications Intraoperative LMA 0 (0.0) 1 (2.4) 0 (0.0) 0 (0.0) 4 (10.0) l(2.5) ETT Tube removal LMA ETT 15 (37.5) 3 (7.3) 1 0 1 2 (2.4) (0.0) (2.7) (5.0) Postoperative LMA 21 (51.2) 4 (9.8) 0 0 7 1 (0.0) (0.0) (17.5) (2.5) ETT 23 (56.1) 3 (7.3) 1 1 9 2 (2.4) (2.4) (22.5) (5.0) LMA Total ETT

Tube placement ETT LMA ETT

LMA Coughing Breathholding Laryngospasm Bronchospasm Spo2 90%-94%

6 (14.6) 7 (17.1) 0 (0.0) 2 (4.9) 0 0 0 0 (0.0) (0.0) (0.0) (0.0) 0 (0.0) 1 (2.4) 1 (2.6) l(2.6)

2 (4.9) 7 (17.1) 1 (2.4) 2 (4.9) 1 0 1 0 (2.4) (0.0) (2.5) (0.0) 1 2 0 5 (2.4) (4.9) (0.0) (12.5)*

3 (7.3) 11 (26.8) 3 (7.3) 5 (12.2) 0 (0.0) 4 (9.8) 3 (7.5) l(2.5) 3 0 3 2 (7.3) (0.0) (7.5) (5.0)

26 (63.4) 33 (80.5) 10 (24.4) 11 (26.8) 4 0 13 4 (9.8) 2 (4.9) 5 (12.2)* (0.0) (32.5) 13 (32.5) (10.0) 10 (25.0)

spoz <90%

Data are n (%). Totals reflect the appearance of at least one episode of a complication more than one episode). LMA = laryngeal mask airway, ETT = endotracheal tube. P < 0.05 versus laryngeal mask airway.

in the perioperative

period and are not a sum total of all episodes (some patients had

These differences were not, however, statistically significant. Interestingly, 42.1% and 38.5% of parents of children in the LMA and ETT groups, respectively, reported that their childs URI symptoms seemed better after anesthesia and surgery. Conversely, 5% of parents whose child had a LMA and 25.6% of parents whose child had an ETT reported a slight worsening of symptoms postoperatively (P < 0.05). This observation was almost entirely attributable to increases in the frequency and severity of cough.

Discussion
Since its inception, the LMA has been the subject of numerous studies in both children and adults (8-14). Recently, Brimacombe (3) performed a meta-analysis of 52 randomized, prospective trials comparing the LMA with the ETT and the FM. In this study, the LMA had 13 advantages over the ETT and 4 over the FM. Advantages over the ETT included increased ease and speed of placement by inexperienced personnel, improved hemodynamic stability during induction and emergence, lower incidence of coughing and sore throat, improved oxygen saturation, and reduced anesthetic requirements for airway tolerance. Disadvantages included lower seal pressures and a higher incidence of gastric insufflation. Compared with the FM, the LMA was easier to use, produced less hand fatigue, improved oxygen saturation, and provided better surgical conditions for pediatric otological cases. The principal disadvantage over the FM was the increased likelihood of esophageal reflux. Despite these many important findings, no study has addressed the use of the LMA for the patient with an URI. The risks associated with anesthetizing a patient with an URI remain controversial. Although some studies suggest that anesthesia for the patient with a respiratory infection increases the risk of complications, including laryngospasm (1,15), bronchospasm (2,16), atelectasis (17), and arterial oxygen desaturation (7,18), others suggest that children with

acute, uncomplicated URIS have no increased morbidity (7,19,20). Certainly, not all children who present for surgery with an URI are suitable candidates to receive an anesthetic. However, if assessment of the patient suggests that the risk/benefit ratio of proceeding is favorable, then the choice of airway management becomes crucial. The FM has generally been considered the method of choice for airway management of children with URIS because it involves minimal stimulation of a potentially irritable airway. In a previous study from our institution, the incidence of laryngospasm in children with URIS undergoing surgery for myringotomy and tube placement with FM anesthesia was 1.28% (19). The FM, however, may not be appropriate for all surgical procedures. Until recently, the only alternative to the FM was the ETT, yet its use in children with URIS has been associated with an increased risk of respiratory complications, including laryngospasm and bronchospasm (1,2). In a study by Cohen and Cameron (l), for example, children with URIS who had an ETT were found to have an 11-fold increase in respiratory complications. Studies of children without URIS who received a LMA have described both breath-holding and laryngospasm; however, these have largely been attributed to inadequate anesthetic depth (4). In a study by McCrirrick et al. (12), 3% of healthy patients who received an LMA experienced mild laryngospasm. Other studies reported an incidence of laryngospasm in healthy children of between 2% and 4% (10,ll). In our study, the incidence of laryngospasm, although higher than that observed in patients without URIS, was similar between the two groups. All but one episode of laryngospasm were described as mild. Coughing is an important complication, because it may be a precursor of laryngospasm. In this study, cough was observed to be less severe during placement of the LMA. Holden et al. (14) found that coughing was also less frequent during removal of the LMA.

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In addition, the degree of oxygen desaturation observed during tube placement was statistically less in the LMA group. This observation seems consistent with studies of patients without URIS. In a study by Watcha et al. (21), Spo, decreased significantly after insertion of an ETT but was unchanged after placement of an LMA. In our study, the greater degree of desaturation observed during placement of the ETT may have been associated with the severity of coughing noted in the ETT group at that time. Olsson and Hallen (15) found that the incidence of bronchospasm in children increases lo-fold when a respiratory tract infection is present. Additionally, Rolf and Cote (2) showed that children with URIS have an increased risk of bronchospasm if the trachea is intubated. In their study, 13.3% of intubated children with an URI experienced bronchospasm. This is very similar to the 12.2% incidence observed among the ETT group in our study and lends external validity to our results. Although all but one episode of bronchospasm were described as mild, the fact that no bronchospasm was observed in the LMA group may suggest an important advantage of the LMA over the ETT in this population of children. Several studies have demonstrated a high incidence of sore throat in patients receiving an ETT compared with a LMA. In children without URIS, the incidence of postoperative sore throat after placement of an LMA is between 4% and 12% (4), whereas one study of intubated patients described an incidence of 49% (6). Although there was no statistical difference in the incidence of postoperative sore throat between the two groups in our study, the fact that almost twice as many patients in the ETT group experienced this complication seems clinically relevant. It should be emphasized, however, that some of the children were preverbal, and, therefore, some of these observations were based solely on the parents interpretation of the childs symptoms and may not reflect a true incidence. One of the difficulties in this type of study is the definition of an URI. Previous studies from our institution have attempted to address this issue by using predetermined symptom criteria (7,19,20). These criteria have since been used by other researchers (2). However, Schreiner et al. (22) suggested that the parents perception as to whether the child has an URI is a better predictor of severe laryngospasm than the use of predetermined criteria. Therefore, for the purposes of this study, although we took note of the patients presenting URI symptoms, the diagnosis of an URI required confirmation by a parent. Another issue of importance in interpreting the results of this study is the relative depth of anesthesia in the two groups. Although both types of airways were inserted under deep anesthesia, it could be argued that the level of stimulation from ETT placement is greater than that with LMA placement. The observed

higher incidence of respiratory complications in the ETT group could therefore be confounded by this difference. However, in our institution, it is common practice to place an ETT under deep anesthesia without the use of muscle relaxants. As a result, it is difficult to eliminate any differences in the level of stimulation between the two groups. Furthermore, in clinical practice, the level of anesthesia required for both types of airway is typically based on crude clinical signs, which make it difficult to quantify any differences in anesthestic depth or level of stimulation. Results from this study suggest that if the decision is made to proceed with anesthesia for patients with uncomplicated URIS, then the LMA provides an acceptable alternative to the ETT. This does not imply that the ETT is necessarily unacceptable for children with an URI, but given its ease of use and its apparent reduced propensity for coughing, bronchospasm, and oxygen desaturation, the LMA seems to offer several advantages over the ETT for airway management in this group of patients. These findings should be considered when choosing a method of airway maintenance for children with acute uncomplicated URIS undergoing elective surgery.
The authors recruitment thank Monica Siewert, and data collection. BA, for her help with patient

References
1. Cohen MM, Cameron CB. Should you cancel the operation when a child has an upper respiratory tract infection? Anesth Analg 1991;72:282-8. 2. Rolf N, Cote CJ. Frequency and severity of desaturation events during general anesthesia in children with and without upper respiratory infections. J Clin Anesth 1992;4:200-3. 3. Brimacombe J. The advantages of the LMA over the tracheal tube or facemask: a meta-analysis. Can J Anaesth 1995;42: 1017-23. 4. Pennant JH, White PF. The laryngeal mask airway: its uses in anesthesiology. Anesthesiology 1993;79:144-63. 5. Smith I, White PF. Use of the laryngeal mask airway as an alternative to a face mask during outpatient arthroscopy. Anesthesiology 1992;77:850-5. 6. Alexander CA, Leach AB. Incidence of sore throats with the laryngeal mask airway [letter]. Anaesthesia 1989;44:791. 7. Levy L, Pandit UA, Randel GI, et al. Upper respiratory tract infections and general anesthesia in children: perioperative complications and oxygen saturation. Anaesthesia 1992;47: 678-82. 8. Benumof JL. Laryngeal mask airway: indications and contraindications. Anesthesiology 1992;77:843-6. 9. Brain AIJ, McGhee TD, McAteer EJ, et al. The laryngeal mask airway: development and preliminary trials of a new type of airway. Anaesthesia 1985;40:356-61. 10. Broderick PM, Webster NR, Nunn JF. The laryngeal mask airway: a study of 100 patients during spontaneous breathing. Anaesthesia 1989;44:238-41. 11. Mason DG, Bingham RM. The laryngeal mask airway in children. Anaesthesia 1990;45:760-5. 12. McCrirrick A, Ramage DTO, Pracilio JA, Hickman JA. Experience with the laryngeal mask airway in two hundred patients. Anaesth Intensive Care 1991;19:256-60.

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DF, Collins SRC, Heath ML. The laryngeal 13. Harris TM, Johnston mask airway in pediatric anaesthesia. Anaesthesia 1990;45: 924 -7. 14. Holden R, Morsman CDG, Butler J, et al. h-&a-ocular pressure changes using the laryngeal mask airway and tracheal tube. Anaesthesia 1991;46:922-4. 15. Olsson GL, Hallen B. Laryngospasm during anesthesia: a computer-aided incidence study in 136,929 patients. Acta Anaesthesiol Stand 1984;28:567-75. 16. Olsson GL. Bronchospasm during anesthesia: a computer-aided incidence study of 136,929 patients. Acta Anaesthesiol Stand 1987;31:244-52. 17. McGill WA, Coveler LA, Epstein BS. Subacute upper respiratory . infection in children. Anesth Analg 1979;58:33i-3. 18. DeSoto H. Pate1 RI, Soliman IE, Hannallah RS. Chances in oxygen saturation following general anesthesia in childre; with upper respiratory signs and symptoms undergoing otolaryngological procedures. Anesthesiology 1988;68:276-9.

19. Tait AR, Knight PK. The effects of anesthesia on upper respiratory tract infections in children. Anesthesiology 1987;67:930-5. 20. Tait AR, Knight PK. Intraoperative respiratory complications in patients with upper respiratory tract infections. Can J Anaesth 1987;34:300-3. 21. Watcha MF, White PF, Tychsen L, Stevens JL. Comparative effects of laryngeal mask airway and endotracheal tube insertion on intraocular pressure in children. Anesth Analg 1992;75: 355- 60. 22. Schreiner MS, OHara I, Markakis DA, Politis GD. Do children who experience laryngospasm have an increased risk of upper respiratory tract infection? Anesthesiology 1996;85:475-80.