A comparison of the laryngeal mask airway with facemask and oropharyngeal airway for manual ventilation by critical care nurses in children
Authors: Rechner J.A , Loach V.J , Ali M.T , Barber V.S , Young J.D , Mason D.G 
Published: May 2007

Introduction:  The European Resuscitation Council recommends the laryngeal mask airway (LMA) for manual ventilation in adult resuscitation if the skills required for the placement of a tracheal tube are unavailable or intubation proves impossible (1). This followed concerns about the ability of inexperienced personnel to provide manual ventilation using traditional facemask and oropharyngeal airway (FM/OA). If inadequate FM/OA ventilation also occurs in children, the LMA may improve airway management during resuscitation.

Methods:  Local ethical approval was obtained. We trained 19 nurses, experienced in paediatric intensive care, emergency medicine or anaesthetics in the use of the LMA on manikins. They all had prior experience in FM/OA ventilation. Children undergoing elective surgery were studied. Anaesthesia was induced with propofol (3–5 mg·kg−1) or sevoflurane (8% in oxygen/nitrous oxide) followed by a continuous infusion of propofol/remifentanil to produce apnoea. Standard monitoring was applied and an ultrasound sensor placed above the xiphisternum to measure anterior posterior (AP) chest expansion. The consultant paediatric anaesthetist manually ventilated the lungs using FM/OA. The AP chest expansion achieved was defined as the gold standard. The nurse then inserted each airway device in random order and chest expansion was compared with the gold standard. A maximum of three attempts was allowed for each airway device. Prior to the study commencing adequate ventilation was defined as successful if 60% or more of the ‘gold standard’ AP chest expansion was achieved.

Results:  The 60 children studied had a median age of 4 years (range 7 months–8 years), and median weight of 17 kg (range 8–41 kg). Using an LMA the nurses achieved successful ventilation in 78% of children compared with 71% in the FM/OA group (P = 0.39, chi‐squared test). The LMA was inserted successfully at the 1st attempt in 60%, 2nd attempt in 11% and 3rd attempt in 6% of children. Median time to first successful breath was 38 s (range 11–147 s) for the LMA and 24 s (range 15–48 s) for the FM/GA. (Figure 1).

 A cumulative frequency plot of the time to first successful ventilation using the laryngeal mask airway or face mask and oropharyngeal airway.

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Discussion:  Critical care nurses can be trained to provide successful ventilation in 78% of children using an LMA. Similar studies in adults have shown a higher proportion of successful LMA insertions than this but the proportion of children successfully ventilated using FM/OA (70%) was higher than in adult studies. This may be because FM/OA ventilation is easier in children. Time to successful ventilation was faster in the FM/OA group than the LMA group, similar to adult studies. In this group of nurses the LMA may not usefully improve the proportion of children ventilated successfully compared with FM/OA.

Acknowledgements:  This study received funding from the Resuscitation Council (UK).

Reference  1 Baskett P. Guidelines for the advanced management of the airway and ventilation during resuscitation. A statement by the Airway and Ventilation Management of the Working Group of the European Resuscitation Council. Resuscitation 1996: 31: 201–230.