What airway device is recommended for a sentinel lymph node biopsy under general anesthesia?

Airway Management for Sentinel Lymph Node Biopsy Under General Anesthesia

A supraglottic airway (laryngeal mask airway) is the preferred airway device for sentinel lymph node biopsy under general anesthesia, as this short-duration superficial procedure does not require endotracheal intubation and the supraglottic airway reduces perioperative respiratory complications.

Primary Recommendation

• Use a supraglottic airway (LMA) rather than endotracheal intubation for sentinel lymph node biopsy. 1 This recommendation is based on French guidelines for airway management during short-lasting elective superficial surgery, which found that supraglottic airways reduce the incidence of laryngospasm and hypoxemia during device removal compared to tracheal intubation. 1

• The evidence supporting supraglottic airways for brief superficial procedures comes from multiple meta-analyses and randomized controlled trials showing significantly fewer perioperative respiratory adverse events with LMA use. 1 In pediatric populations undergoing minor surgery, the relative risk of respiratory adverse events was nearly 3 times higher with endotracheal intubation, and the risk of laryngospasm and bronchospasm was 5 times greater. 1

Clinical Reasoning

Sentinel lymph node biopsy is a short-duration, superficial procedure that does not involve:

• Airway manipulation or sharing of the surgical field with the airway 1
• Risk of aspiration (assuming appropriate NPO status) 1
• Need for positive pressure ventilation beyond what an LMA can provide 1
• Prolonged operative time requiring deep muscle relaxation 1

The supraglottic airway provides adequate ventilation and oxygenation while minimizing airway trauma and hemodynamic stress compared to endotracheal intubation. 2

Practical Implementation

• Select an appropriately sized LMA based on patient weight 1
• Ensure adequate depth of anesthesia before insertion to prevent laryngospasm 1
• Confirm adequate ventilation after placement with capnography 1
• Use a bite block to protect the device if needed 1

When Endotracheal Intubation May Be Necessary

Consider endotracheal intubation instead of an LMA if the patient has:

• Significant aspiration risk (active GERD, full stomach, gastroparesis) 1
• Anticipated difficult mask ventilation that cannot be managed with an LMA 1
• Severe obesity with difficult LMA placement 1
• Inability to tolerate brief apneic episodes (severe pulmonary disease) 1

The ASA Difficult Airway Guidelines emphasize that any single factor—including increased aspiration risk or inability to tolerate desaturation—may warrant a different airway approach. 1

Common Pitfalls to Avoid

• Do not use endotracheal intubation routinely for this procedure. Intubation increases the risk of cough, laryngospasm, and hemodynamic instability during emergence without providing additional benefit for superficial surgery. 1

• Do not remove the LMA at an arbitrary depth of anesthesia. While guidelines show no clear superiority for deep versus awake removal, anticipate potential upper airway obstruction with deep removal and be prepared with jaw thrust or oral airway. 1

• Ensure adequate pre-oxygenation and monitoring throughout the procedure, as respiratory complications primarily occur during emergence. 1

Alternative: Local Anesthesia

For patients who are poor candidates for general anesthesia, sentinel lymph node biopsy can be performed effectively under local anesthesia with similar detection rates and outcomes. 3, 4 This approach eliminates airway management concerns entirely and may be preferred in high-risk patients.