Device stability and quality of ventilation of classic laryngeal mask airway versus AIR-Q and I-gel at different head and neck positions in anesthetized spontaneously breathing children.

BACKGROUND: Since its introduction into clinical practice, the use of laryngeal mask airway (LMA) has been dramatically increasing. We aimed to investigate the clinical performance of single use LMA classic, AIR-Q and I-gel at different head and neck positions and during the operative procedure in pediatric elective day case surgery. METHODS: One hundred sixty-eight generally anesthetized spontaneously breathing children (2-9 years) were randomized to receive either LMA classic (N.=56), I-gel (N.=58) or AIR-Q (N.=54). The oropharyngeal leak pressure (OLP), exhaled tidal volume (TV), peak inspiratory pressure (PIP), ventilation score and fiberoptic glottis view score were assessed at neutral position then at maximum flexion, extension and left rotation. Afterwards, the ventilation and fiberoptic view scores were assessed in neutral position at fixed time-points until end of surgery. RESULTS: Compared to neutral position, maximum neck flexion increased OLP (P=0.000) and compromised the ventilation leading to increased PIP, decreased TV, worsening of ventilation score and fiberoptic glottis view. OLP mildly decreased with extension and left lateral rotation with mild effect on ventilation parameters (P<0.05). At all neck positions, the OLP was higher (P=0.000) and ventilation parameters were better with I-gel (P=0.000). Gradual worsening of ventilation score and fiberoptic view grade was recorded intraoperatively with the three devices, with the least deterioration observed in I-gel group (P=0.000). CONCLUSIONS: Having the highest increase in OLP at neck flexion, the I-gel LMA exhibited the best ventilation parameters and fiberoptic view grade at different head and neck positions and throughout the intraoperative period.

Post-extubation continuous positive airway pressure improves oxygenation after pediatric laparoscopic surgery: A randomized controlled trial.

BACKGROUND: Effects of intraoperative recruitment maneuvers (RMs) on oxygenation and pulmonary compliance are lost during recovery if high inspired oxygen and airway suctioning are used. We investigated the effect of post-extubation noninvasive CPAP mask application on the alveolar arterial oxygen difference [(A-a) DO2 ] after pediatric laparoscopic surgery. METHODS: Sixty patients (1-6 years) were randomly allocated to three groups of 20 patients, to receive zero end-expiratory pressure (ZEEP group), RM with decremental PEEP titration only (RM group), or followed with post-extubation CPAP for 5 minutes (RM-CPAP group). Primary outcome was [(A-a) DO2 ] at 1 hour postoperatively. Secondary outcomes were respiratory mechanics, arterial blood gas analysis, hemodynamics, and adverse events. RESULTS: At 1 hour postoperatively, mean [(A-a) DO2 ] (mm Hg) was lower in the RM-CPAP group (41.5 ± 13.2, [95% CI 37.6-45.8]) compared to (80.2 ± 13.7 [72.6-87.5], P < 0.0001] and (59.2 ± 14.6, [54.8-62.6], P < 0.001) in the ZEEP and RM groups. The mean PaO2 (mm Hg) at 1 hour postoperatively was higher in the RM-CPAP group (156.2 ± 18.3 [95% CI 147.6-164.7]) compared with the ZEEP (95.9 ± 15.9 [88.5-103.3], P < 0.0001) and RM groups (129.1 ± 15.9 [121.6-136.5], P < 0.0001). At 12 hours postoperatively, mean [(A-a) DO2 ] and PaO2 were (9.6 ± 2.1 [8.4-10.8]) and (91.9 ± 9.4 [87.5-96.3]) in the RM-CPAP group compared to (25.8 ± 5.5 [23.6-27.6]) and (69.9 ± 5.5 [67.4-72.5], P < 0.0001) in the ZEEP group and (34.3 ± 13.2, [28.4-40.2], P < 0.0001) and (74.03 ± 9.8 [69.5-78.6], P < 0.0001) in the RM group. No significant differences of perioperative adverse effects were found between groups. CONCLUSIONS: An RM done after pneumoperitoneum inflation followed by decremental PEEP titration improved oxygenation at 1 hour postoperatively. The addition of an early post-extubation noninvasive CPAP mask ventilation improved oxygenation at 12 hours postoperatively.