Pediatric Anesthesia ISSN 1155-5645

REVIEW ARTICLE

Supraglottic airway devices vs tracheal intubation in children: a quantitative meta-analysis of respiratory complications  Michelet1,2, Julie Hilly1,2, Virginie Luce1,2, Hakim Harkouk1,2, Christopher Brasher1,2, Daphne 1,2 1,2 1,2 Matthieu Maesani , Thierno Diallo , Nyamjargal Mangalsuren , Yves Nivoche1,2 & Souhayl Dahmani1,2,3  University Hospital, Paris, France 1 Department of Anesthesia, Intensive Care, RobertDebre , Paris, France 2 University Paris Diderot, Paris VII. Paris Sorbonne Cite  University Hospital, Paris, France 3 INSERM UMR U 676, Robert Debre

Keywords laryngeal mask; tracheal intubation; laryngospasm; children; bronchospasm; respiratory complications; airway; desaturation Correspondence Souhayl Dahmani, Department of Anesthesia, Intensive Care and Pain  Hospital, 48 Bd Management, Robert Debre rurier, 75019 Paris, France Se Email: [email protected] Section Editor: Jerrold Lerman Accepted 29 June 2014 doi:10.1111/pan.12495

Summary Background: Rate of perioperative respiratory complications between tracheal intubation (TI) and laryngeal mask airway remains unclear during pediatric anesthesia. Objectives: The aim of the present meta-analysis was to compare the perioperative respiratory complications between laryngeal mask airway and TI. Methods: A meta-analysis of available controlled studies comparing laryngeal mask airway to TI was conducted. Studies including patients with airway infection were excluded. Data from each trial were combined to calculate the pooled odds ratios (OR) or mean difference (MD) and 95% confidence intervals. Results: The meta-analysis was performed on 19 studies. In 12 studies, patients were given muscle relaxation, and in 16 studies, ventilation was controlled. During recovery from anesthesia, the incidence of desaturation (OR = 0.34 [0.19–0.62]), laryngospasm (OR = 0.34 [0.2–0.6]), cough (OR = 0.18 [0.11–0.27]), and breath holding (0.19 [0.05–0.68]) was lower when laryngeal mask airway was used to secure the airway. Postoperative incidences of sore throat (OR = 0.87 [0.53–1.44]), bronchospasm (OR = 0.56 [0.25–1.25]), aspiration (1.33 [0.46–3.91]) and blood staining on the device (OR = 0.62 [0.21–1.82]) did not differ between laryngeal mask airway and TI. Results were homogenous across the studies, with the exceptions of blood staining on the device. Conclusions: This meta-analysis found that the use of laryngeal mask airway in pediatric anesthesia results in a decrease in a number of common postanesthetic complications. It is therefore a valuable device for the management of the pediatric airway.

Introduction Respiratory complications remain a great concern in pediatric anesthesia, and airway management is crucial in their prevention. They are a relatively common cause of major complications such as cardiac arrest during the perioperative (intra- and postoperative) management of surgical patients (1). © 2014 John Wiley & Sons Ltd

Pediatric respiratory adverse events often occur due to respiratory tract reactivity secondary to mechanical or chemical stimulation perioperatively (2). Common stimulants include assisted ventilation, nociception, and aspiration. Respiratory tract infections in the preceding 2 weeks have also been shown to exacerbate airway reactivity (2,3). Consequently, many studies have been conducted over the last two decades to evaluate and 1

V. Luce et al.

Laryngeal mask vs. tracheal tube in pediatrics

describe optimal pediatric anesthetic conditions. Most identify ongoing and recent upper respiratory tract infection (URTI) as a major cause of perioperative (intra- and postoperative) respiratory complications and suggest careful management in emergent conditions or delaying surgery where possible (3). The relative advantages and disadvantages of laryngeal mask airway and TI concerning the occurrence of respiratory complications continue to be debated in the literature. Many supraglottic mask airway devices have recently been introduced in pediatric airway sizes (Proseal laryngeal mask airway, i-Gel, flexible laryngeal mask airway). Studies have assessed optimal insertion (4), ventilation modalities (5), depth of anesthesia (6), and correct placement (7) in comparison with tracheal intubation. However, the relative respiratory complication advantages for laryngeal mask airway and TI remain controversial in pediatric populations. A recent adult patient meta-analysis highlighted a reduction in emergent respiratory complications such as laryngospasm, coughing, and sore throat with laryngeal mask airway use (8). The authors wanted to conduct a metaanalysis to compare perioperative respiratory complications when using laryngeal mask airway and TI to secure the airway during pediatric anesthesia. Material and methods Bibliographical search and analysis We conducted this meta-analysis according to the Cochrane Handbook for systematic reviews of intervention guidelines, PRISMA statements, and Cochrane statistical methods guidelines (9,10). Research was performed on Pubmed and Embase databases from January 1, 1960, to December 31, 2013. The following whole text queries were used: ‘name of the laryngeal mask and children or infant.’ Names included were laryngeal mask, flexible laryngeal mask, proseal laryngeal mask, and i-gel. In addition, a manual search of references cited in articles that were selected was also performed. The most recent search date was September 2013. Articles were analyzed by four physicians to verify their relevance: use of laryngeal mask and tracheal intubation in respective arms and the absence of current respiratory tract infection. Readers also assessed the potential risk of bias as recommended by Cochrane experts (9): randomization and allocation concealment (clear description of method in sufficient detail to determine whether intervention allocations could have been foreseen before or during enrollment), a minimum of simple blinding (double blinding was not possible during airway management), the presence of an 2

incomplete data report statement about excluded patients and data, and the absence of selective reporting (studied outcomes report). Studies were excluded if bias was found to be present, anesthesia and/or analgesia protocols were not standardized and comparable between the two groups, and if patients had anatomical respiratory tract abnormalities or were at risk of a full stomach. Respiratory complication outcomes from insertion to the postoperative period were analyzed. They included overall complications, laryngospasm, bronchospasm, desaturation, aspiration, blood staining of the device, cough, and sore throat. In addition, postoperative care unit (PACU) stay duration was also analyzed. Although not a postoperative complication in itself, PACU stay duration can be considered as a proxy of respiratory recovery. When conflicting results were reported, the article was rechecked by two different anesthesiologists. Statistical analysis Statistical analysis was performed using the Review Manager 5 software (RevMan 5, The Cochrane Collaboration, Oxford, UK). The Mantel-Haenszel odds ratio (OR, discrete outcomes) was calculated for perioperative respiratory complications and 95% confidence intervals. The mean difference (MD, continuous outcomes) was calculated for PACU stay durations, with 95% confidence intervals. An OR 95% confidence interval of

Supraglottic airway devices vs tracheal intubation in children: a quantitative meta-analysis of respiratory complications.

Rate of perioperative respiratory complications between tracheal intubation (TI) and laryngeal mask airway remains unclear during pediatric anesthesia...
344KB Sizes 0 Downloads 4 Views