Episode #143 Safe Use of Supraglottic Airway Devices During Laparoscopic Surgery

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. What is your anesthetic plan for patients undergoing laparoscopic surgery? Perhaps you start with an IV induction, followed by placement of an endotracheal tube and then multi-modal analgesia and PONV prophylaxis…Wait, what’s that? You didn’t place an endotracheal tube? You placed a supraglottic device? For laparoscopic surgery? This sounds like something that we need to talk about!

Before we dive into the episode today, we’d like to recognize BD, a major corporate supporter of APSF. BD has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, BD – we wouldn’t be able to do all that we do without you!”

Our featured article is from the February 2023 APSF Newsletter. There are so many great articles in this newsletter. Today, we are discussing “Supraglottic Airway Devices (SADs) and Laparoscopic Surgery” by Shauna Schwartz and Yong Peng. To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is the current issue. Then, scroll down until you get to our featured article today. I will include a link in the show notes as well.

Before we get into this new article, let’s head into the recent archives because Schwartz and Peng are the authors from the October 2021 APSF Newsletter article, ““The Laryngeal Mask Airway: Expanding Use Beyond Routine Spontaneous Ventilation for Surgery.” We covered the expanding uses for laryngeal mask airway devices on Episodes #76 and #77. These episodes were so popular that we revisited this topic for Episode #112 which is the top downloaded episode of the Anesthesia Patient Safety Podcast. Clearly, this is an important topic for anesthesia professionals who are dedicated to keeping patients safe! We hope that you can check out these past shows and we are so excited to continue the conversation today.

We continue to see enthusiasm for using supraglottic airway devices during anesthesia care for a variety of different procedures including laparoscopic surgical procedures. At the same time, there is an ongoing debate about the safety and efficacy of these airway devices when used during laparoscopic surgery. Stay tuned as we review the considerations for keeping patients safe with a supraglottic airway device during laparoscopic surgery.

The expanding use of the supraglottic airway device may be attributed in part due to design changes over the years leading to an improved safety profile.  The classic laryngeal mask airway is a first-generation device developed by Teleflex. Its simple design allows hands free ventilation while a patient breathes spontaneously and may help to relieve upper airway obstruction and has an important role on the difficult airway algorithm. Second generation devices allow for increased oropharyngeal leak pressures with enhanced protection against gastric aspiration as well as improved ability to deliver positive pressure ventilation.

When deciding to place a supraglottic airway device or an endotracheal tube it is important to weigh the risks and benefits. The authors tell us that there may be improved hemodynamic stability when supraglottic airway devices are used during laparoscopic surgery. A 2012 study in Anesthesiology by Carron and colleagues looked at hemodynamics and catecholamine levels in obese patients undergoing laparoscopic gastric banding. Patients were randomized to receive an endotracheal tube or a ProSeal Laryngeal Mask Airway. Patients with an endotracheal tube had higher blood pressures and higher circulating catecholamine levels during the procedure compared to patients with the laryngeal mask airways. There is a real risk to patients from increased catecholamine levels which may increase a patient’s heart rate leading to increased myocardial oxygen demand with decreased myocardial oxygen supply. There may be an increased risk of a prothrombotic state as well. Increased circulating catecholamines may increase the risk for perioperative complications in certain high-risk populations and these patients in particular may benefit from the use of a supraglottic airway device rather than an endotracheal tube.

There is less sympathetic stimulation during placement of a supraglottic airway device which may require less anesthesia leading to less risk for hypotension from reductions in systemic vascular resistance and less myocardial depression. High risk patients may not tolerate the catecholamine surgery and the increased anesthetic requirements for intubation with an endotracheal tube and may be managed safely with placement of a laryngeal mask airway.

Let’s continue with a comparison of supraglottic airway devices and endotracheal tubes. That’s right, it’s time for a literature review. Supraglottic airway devices may be associated with less airway complications. For patients undergoing surgery at an ambulatory surgery center, there was a lower incidence of sore throat for patients with a supraglottic airway device compared to an endotracheal tube at 17.5% and 45.5% respectively. In 2016, a meta-analysis evaluated differences between supraglottic airway devices and endotracheal tubes for patients undergoing elective laparoscopic surgery. In terms of clinical performance, there was no difference in the following: first pass insertion success, insertion time, and oropharyngeal leak pressure. There was also no difference in the incidence of the following events during the surgery: desaturation, gastric insufflation, regurgitation, and aspiration. The differences between the groups emerged at the complications since there was a higher incidence of laryngospasm, dysphagia, dysphonia, sore throat, and hoarseness in the endotracheal tube group. I will include the citation in the show notes.

For pediatric patients who have had recent upper respiratory infections, there may be an increased risk for respiratory complications including bronchospasm and laryngospasm when an endotracheal tube is placed compared to a supraglottic airway device. Let’s look at the 1998 study by Tait and colleagues which included 82 pediatric patients aged 3 months to 16 years with a recent respiratory infection for elective surgery who were randomized to receive an endotracheal tube or an LMA. Patients with an endotracheal tube had an increased incidence of bronchospasm and desaturation with an SpO2 less than 90% during airway management compared to patients with a supraglottic airway device. More recently, a 2020 study evaluated respiratory complications in pediatric patients undergoing laparoscopic hernia repair. The results revealed a decreased rate of laryngospasm, cough, and desaturation in patients with a supraglottic airway device compared to an endotracheal tube. In patients at high risk for bronchospasm, laryngospasm, and desaturation, use of a supraglottic airway device may help to decrease the risk of perioperative respiratory complications. The benefits for use of a supraglottic airway device also include less patient airway complaints and less airway complications.

Another benefit that stems from the decreased airway complications and less hemodynamic instability may be faster time to discharge in patients with a supraglottic airway device. The 2012 study by Carron and colleagues evaluated 75 morbidly obese patients undergoing laparoscopic gastric banding and were randomized to receive a ProSeal LMA or endotracheal tube. The postoperative course revealed the following differences in the LMA group compared to the endotracheal tube group: less episodes of postoperative cough, hypoxemia, and postop nausea and vomiting with faster discharge from the PACU and hospital at 17 minutes and 111 minutes faster respectively. The authors of this study do not recommend use of an LMA instead of an endotracheal tube for laparoscopic gastric banding, but the study suggests that it may be a safe alternative for carefully selected patients with an experienced anesthesia professional.

An important consideration during laparoscopic surgery is the effect of pneumoperitoneum. Physiological changes associated with pneumoperitoneum include increased abdominal pressure, reduced diaphragmatic excursion, and decreased respiratory compliance. These changes can make effective ventilation difficult and increase the risk for gastric regurgitation and aspiration.  The newer supraglottic airway devices have been improved and allow for higher oropharyngeal leak pressure which helps to address these concerns with improved ventilation especially with positive pressure ventilation. In the meta-analysis that we discussed earlier comparing endotracheal tubes and supraglottic airway devices during laparoscopic surgery, the studies revealed no difference in the incidence of oropharyngeal leak pressure or desaturation so safe and effective ventilation is possible with the supraglottic airway devices.

Another meta-analysis evaluated the role of laryngeal mask airway devices in patients undergoing laparoscopic cholecystectomies and found that ventilation was effective in 99.5% of patients with a supraglottic airway device. However, caution is necessary in patients with a BMI greater than 30 who may require placement of an endotracheal tube due to respiratory obstruction or a significant air leak. Adequate ventilation and oxygenation are likely with a supraglottic airway device for non-obese patients undergoing laparoscopic surgery.

Are there other risks for using supraglottic airway devices that we need to consider? What about gastric insufflation from leaking around the device and the risk for aspiration? One of the contraindications for supraglottic airway device placement is aspiration risk especially in high-risk patients. Check out Table 1 in the article which describes patient factors and consideration for supraglottic airway device placement. We are going to review it now.

The first column lists those patients that a supraglottic airway device is beneficial for including fasted patients and patients with a BMI less than 30. The second column lists controversial patients including morbid obesity and patients with a BMI greater than 40. The third column lists the contraindications including unfasted patients and patients at high aspiration risk. While an endotracheal tube is necessary to decrease the risk for aspiration in patients who are unfasted or with a bowel obstruction, a second-generation supraglottic airway device may be used during laparoscopic surgery without putting patients at increased risk for gastric insufflation or aspiration. Leak around the device and gastric insufflation depends on the quality of the seal and positioning of the device. When first-generation supraglottic airway devices were evaluated for positioning with a fiberoptic bronchoscope, 44% were mal positioned but when these devices are correctly positioned there is only a 3% incidence of gastric insufflation. Second-generation devices were designed to help address this risk with better seals and higher oropharyngeal leak pressures with less risk for gastric reflux and aspiration compared to first-generation devices. Another benefit of the newer devices is the gastric port that can drain gastric contents from the airway and can be used for placement of an orogastric tube as well. Studies have revealed that supraglottic airway devices may be used without evidence of aspiration in patients undergoing laparoscopic surgery.

We made it to the end of the article. The authors draw some important conclusions.

• Second-generation supraglottic airway devices may be safe and effective for laparoscopic surgeries in appropriate patients with an improved safety profile in terms of decreased risk for gastric insufflation and aspiration and improved ventilation during pneumoperitoneum.
• First-generation devices may not be appropriate for patients undergoing laparoscopic surgery.
• Benefits of using supraglottic airway devices compared to endotracheal tubes include improved hemodynamic stability, reduced risk of perioperative respiratory complications, reduced airway morbidity and earlier PACU and hospital discharge. These benefits related to supraglottic airway device use are summarized in table 2 as well. I will include this in the show notes as well.

What is your airway management plan for patients undergoing laparoscopic surgery? Do you reach for an endotracheal tube or a second-generation supraglottic airway device? Let us know by tagging us @APSForg using the hashtag #APSFpodcast! We want to hear from you!

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today. Don’t forget to subscribe to the podcast through iTunes or your favorite podcast app and we would love it if you could share this podcast with all of your work colleagues, friends, and family and don’t forget to leave us a five-star review.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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