Airway Management in Children Undergoing Adenotonsillectomies
Condition: Tonsillitis
MeSH terms: Tonsillitis
Study type: Interventional

Summary: 
      Secure airway management is the basis of all anesthesiological practice. Of particular
      importance is the securing of patients' airway passages when the surgical procedure itself
      poses a threat to a patient's airway, as is the case in all procedures involving the upper
      respiratory pathways. When adenoidectomies, tonsillectomies and combined adenotonsillectomies
      are performed, blood from the surgical area will present a respiratory threat to unsecured
      airways. The traditional opinion has been that endotracheal intubation is the safest method
      of preventing aspiration.

      The laryngeal mask was introduced in 1983 as an alternative to the endotracheal tube. In
      1990, the flexible, reinforced laryngeal mask airway was introduced, intended for use during
      surgical procedures involving the mouth and throat. The laryngeal mask airway has several
      potential advantages over the endotracheal tube. It is inserted blindly, without
      laryngoscopy. This leads to reduced oropharyngeal or laryngeal stimulation and injury, and
      therefore minimal activation of respiratory and circulatory reflexes. The laryngeal mask
      airway can be placed without the use of muscle relaxants, avoiding potential side effects
      such as apnea, hyperkalemia and anaphylaxis. In addition the laryngeal mask airway can remain
      in the throat until the patient awakes, virtually eliminating the danger of postoperative
      aspiration.

      Several international studies have described the advantages of the laryngeal mask airway over
      endotracheal intubation during ear, nose and throat surgery in children. The general
      impression is that there is a widespread routine implementation of the laryngeal mask airway.
      In Norway, however, this practice has been limited. As far as we know, only Namsos Hospital
      uses this procedure as its first choice. At Telemark Hospital we tested the use of laryngeal
      mask airway on 150 patients between May and December 2006. The results so far have been
      promising, and we have had no serious complications.

      Hypothesis:

      In children undergoing adenotonsillectomies, a laryngeal mask airway provides greater patient
      satisfaction (judged by reduced pain, nausea and vomiting) and greater effectivity (judged by
      reduced time in surgery), compared with the endotracheal tube. The laryngeal mask provides as
      much as or greater secure airway management measured by desaturations/Sp02<92% and/or use of
      suxamethonium and bronchiolytic drugs.
    

Detailed description: 
      Registration:

      Preoperative: Age, height, weight, medication, asthma/allergy, possible current respiratory
      infection

      Peroperative: Type of procedure, tube size/laryngeal mask, type of tongue blade,
      highest/lowest SpO2, highest/lowest ET CO2, highest/lowest pulse, length of surgery, total
      operating room time, operator, medication. Reason must be given if converting from laryngeal
      mask to tube; lack of visibility for operator, laryngeal mask not possible to place,
      unacceptable leakage before placing tongue blade, occlusion after placement of tongue blade.

      Postoperative: Pain judged by need for opiates (VAS, crying, agitation, tachycardia), nausea
      judged by gagging/vomiting, total time in recovery, rebleeding judged by reoperation.

      Anesthesia:

      Induction: Alfentanil 20 microg/kg body weight Propofol 3-4 mg/kg body weight Or:
      Sevoflurane/N2O mask induction with MAC 1-2

      Maintenance: Alfentanil 5-10 microg/kg body weight every 8-10 minutes Sevoflurane/N2O
      equivalent to 1-1.5 MAC Acetaminophen supp 40 mg/kg body weight, max 2 g. Dexamethasone
      0.15mg/kg body weight Xylocaine 1mg/kg body weight

      Emergence: Morphine 100-200 mikrog/kg body weight

      Postoperative: Morphine 50-100 microg/kg body weight

      Post-discharge: Acetaminophen tbl 15 mg/kg body weight x 3 Or: Acetaminophen supp 20 mg/kg
      body weight x 3

      Patient booklet:

      A patient booklet will be produced for each patient. The booklet will contain only the
      patient's initials, age and research number. After the booklets are filled out, they will be
      stored in a locked facility by one of the examining physicians, and the code to the patient's
      name will be stored and locked separately by one of the researchers. The code will be
      destroyed at the end of the research study.
    

Intervention name(s): Laryngeal mask airway; Endotracheal tube
Intervention type(s): Device; Device
Intervention description(s): Airway management by the use of the flexible, reinforced laryngeal mask airway; Airway management by the use of endotracheal tube
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment