LMA vs Endotracheal Tube in Pediatric Anesthesia
For short-lasting elective superficial surgery in children, use a supraglottic airway (LMA) rather than endotracheal intubation to reduce perioperative respiratory complications, particularly laryngospasm and hypoxemia. 1
Primary Recommendation
The French Society of Anesthesia and Intensive Care guidelines (2019) provide a Grade 2+ recommendation with strong expert agreement favoring LMA over ET tube for appropriate pediatric cases 1. This recommendation specifically targets:
- Short-duration procedures 1
- Elective superficial surgery 1
- Cases where airway protection from aspiration is not a primary concern 1
Evidence Supporting LMA Use
Respiratory Complications
The most compelling evidence comes from Drake-Brockman et al.'s randomized controlled trial in 181 infants (2-12 months) undergoing minor surgery, which demonstrated:
- 2.94-fold increased relative risk of perioperative respiratory adverse events with ET tubes 1
- 5-fold increased risk of laryngospasm and bronchospasm with ET tubes 1
- Significantly reduced overall respiratory complications with LMA 1
Additional Benefits
- Lower incidence of postoperative cough with LMA compared to ET tube 1
- Reduced laryngospasm rates (6.1% vs 22.9% with ET tube) 2
- Lower desaturation events (12.2% vs 37.5% with ET tube) 2
- Decreased severe coughing (6.1% vs 27% with ET tube) 2
When to Choose ET Tube Over LMA
Endotracheal intubation remains the preferred choice when:
- Airway protection from aspiration is required (full stomach, GERD, bowel obstruction) 1
- Prolonged procedures requiring controlled ventilation 1
- Procedures involving the head, neck, or airway itself where surgical field access is needed 1
- Prone positioning or shared airway procedures 1
- Anticipated difficult airway requiring definitive control 1
Critical Technical Considerations
For LMA Use:
- Monitor cuff pressure with a manometer and limit to ≤40 cmH₂O to minimize oropharyngeal pain and optimize seal 1
- Maximum 3 insertion attempts before considering alternative airway management 1
- LMA provides adequate airway protection even in procedures with expected bleeding (e.g., sinonasal surgery), comparable to uncuffed ET tubes with throat packs 3
For ET Tube Use:
- Use cuffed tubes rather than uncuffed tubes in all pediatric patients (Grade 1+ recommendation with strong agreement) 1
- Monitor cuff pressure and maintain ≤20 cmH₂O 1
- Cuffed tubes reduce reintubation rates for excessive air leak without increasing post-extubation complications 1
- Cuffed tubes significantly reduce tidal volume loss (10.62-fold lower odds) and need for immediate reintubation (5.54-fold lower odds) compared to uncuffed tubes 4
Common Pitfalls to Avoid
Do not assume LMA is contraindicated in procedures with anticipated bleeding. Evidence demonstrates LMA provides comparable airway protection to uncuffed ET tubes with throat packs in sinonasal surgery, with only 3.3% laryngeal blood contamination rate 3.
Do not inflate cuffs based on clinical assessment alone. Both LMA and ET tube cuffs require manometric monitoring, as clinical assessment consistently results in excessive pressures 1.
Do not persist with multiple LMA insertion attempts beyond 3 tries. Failed LMA placement after 3 attempts requires transition to alternative airway management per difficult airway algorithms 1.
Device Removal Considerations
No specific recommendation exists for removing LMA under deep anesthesia versus fully awake 1. Meta-analysis shows:
- No difference in laryngospasm or desaturation rates between deep and awake removal 1
- Increased upper airway obstruction risk with deep removal, but easily managed with jaw thrust or oral airway 1
- More coughing with awake removal 1
The choice should be based on anticipated risk of upper airway obstruction and ability to rapidly intervene if needed 1.