Efficacy of laryngeal airway mask compared with endotracheal tube in reducing coughing following general anesthesia in adults

Document Type : Systematic review

Authors

1 Department of Anesthesiology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

2 Department of Gynecology, School of Medicine, Mashhad University of Medical Science, Mashhad, Iran.

Abstract

Introduction: Coughing is an airway complication that could affect the outcome of surgery following general anesthesia in adults. In this systematic review, we aimed to study the efficacy of applying laryngeal airway mask (LMA) compared with endotracheal tube (ETT) in reducing the postoperative cough in adults under general anesthesia.
Method: PubMed was searched for the relevant articles. Inclusion criteria were all the randomized controlled clinical trials, which used LMA and ETT in adults under general anesthesia. Only English language articles were included in this study with no time limitation.
Result: Overall, 15 articles were retrieved, which were relevant with the purpose of this study. Efficacy of LMA in reducing coughing was significantly different with ETT in adults under general anesthesia in various types of surgeries. Calculated number needed to treat (NNT) showed that using LMA would significantly reduce coughing even in one adult patient.
Conclusions: Coughing has shown various adverse effects on postoperative main results in some surgeries such as cataract, cranial, etc. Applying LMA could positively decrease postoperative coughing in adults.

Keywords

Full Text

Introduction
General anesthesia may induce respiratory complications in which the protective effect of airway reflexes will be decreased. Respiratory complications are among serious issues during each surgery that should be accurately managed to inhibit associated morbidity such as cardiac arrest during the peri-, intra-, and postoperative management. The ability to protect patent airway and provide effective positive pressure ventilation (PPV) is a principal during any anaesthesiological events (1).
Endotracheal tube (ETT) is commonly applied for managing respiration in a setting of general anesthesia which is mostly used in severely injured patients, or anesthetized patients to inhibit asphyxiation or airway obstruction. EET has been proposed as the main standard method for maintaining airway from aspiration (2). Applying this device needs sufficient operator expertise and has some limitation from different anatomical points of view including (3) local trauma, stress-response reflex, and malpositioning of the ETT.
The laryngeal mask airway (LMA), invented in 1983 by Dr Archie I. J. Brain, is a supraglottic airway device suggested as a beneficial alternative for managing and monitoring respiration during spontaneous or controlled ventilation in adults and children (4). Compared with ETT, the prevalence of using LMA is increasing due to its less invasive characteristics and minimal associated cardiovascular, respiratory, and postsurgical airway complications and disturbances (5). Using LMA has some advantageous over ETT, including no manipulation of patients` neck, jaw, and head, no compression of facial nerves, lower hemodynamic stress response, and low incidence of cerebral hemorrhage, fast and easy placement and stable positioning, no tracheal edema, improved oxygen saturation, and lower incidence of sore throat in adults (6,7). However, there are various possible disadvantages of LMA such as: gastric insufflation and aspiration, inadequate alveolar ventilation, and impossibility of suctioning the airway or using drugs endotracheally (8,9).
Postoperative respiratory tract complications are important to be controlled due to the possibility of threatening surgery outcomes (10). Postoperative coughing can increase the venous pressure that can lead to increased cerebral blood flow, intracranial pressure, and regional brain oxygen saturation (11).
In this systematic review, we study the differences reported in literature between ETT and LMA during general anesthesia in adults regarding the incidence of coughing as an air-related complication.

Methods
We searched PubMed to retrieve all the relevant articles to the clinical question of this study with the following search term: (laryngeal airway mask OR LMA) and (endotracheal tube OR ETT). Coughing was considered as the outcome of the included studies. No date limitation was included in  search strategy of this study. Only English language articles were selected to be extracted. Reference lists of the included articles were also searched manually to prevent missing any relevant article. Irrelevant articles were omitted by studying the title, abstract, and eventually the full text of the obtained articles, at first search. Inclusion criteria were all the randomized controlled clinical trials that studied the efficacy of LMA and ETT in adults undergoing general anesthesia during any surgical operation. Exclusion criteria were all the different types of articles and case reports, studies on pediatrics, experimental studies, non-English language articles, and those that did not compare LMA and ETT. Data on authors, patients’ characteristics, surgery type, percent of coughing in each study, and odds ratio as the effect size of each article are expressed in Table 1.

Results
Overall, 484 articles were found at the initial search that some were excluded after studying the title, abstract, and the full text. Eventually, 15 articles were included in this study for data extraction as the most relevant studies to the question of this review. Flowchart of the main studies is presented in Figure 1.
 included studies showed the significant differences between LMA and ETT regarding the incidence of coughing during the recovery time of patients under general anesthesia in different types of surgeries.
NNT which has been presented in Table 1 for each study shows that applying LMA significantly reduces the incidence of coughing compared with ETT in surgeries with general anesthesia.
Higher incidence of coughing by using ETT during general anesthesia might be due to the insertion process of ETT in trachea, which can irritate the airway and lead to the incidence of postoperative respiratory complications (12).
Evaluating the incidence of coughing and other associated airway complications has a clinical importance for choosing the best treatment approach. It seems that the incidence of coughing during recovery time can increase the possibility of further postoperative complications in some specific surgeries.
According to the study of Akhtar et al., coughing could increase the intraocular pressure to more than 50 mmHg, which was unfavorable following cataract and intra-ocular ophthalmic surgeries and could lead to iris or vitreous prolapse (12); thus it should be inhibited. Similar results would happen regarding increased intracranial pressure by coughing during cranial surgeries (26). Intraocular increased pressure is specifically vital in patients undergoing eye injuries. In this regard, applying LMA could inhibit the possibility of compromising outcomes of some surgeries by reducing the incidence of coughing. Webster et al. mentioned that coughing could increase the possibility of bleeding following intranasal surgeries (25).
Sharma et al. mentioned that pulmonary functions were depressed in lower level compared with other surgeries during peripheral limb surgeries, therefore applying LMA could reduce the possibility of coughing and the consequence postoperative complications (27).

Conclusion
This study showed that using LMA as a suitable alternative for ETT in adults could significantly reduce the incidence of coughing, an airway complication following general anesthesia.

Acknowledgement
We would like to thank Clinical Research Development Unit of Ghaem Hospital for their assistant in this manuscript.

Conflict of Interest
The authors declare no conflict of interest.

References

  1. Trevisanuto D, Micaglio M, Ferrarese P, et al. The laryngeal mask airway: potential applications in neonates. Arch Dis Child Fetal Neonatal Ed. 2004;89:F485-489.
  2. Hartman MT, Lang J. Clinical benefits of visualization of airway anatomy and manipulation of the endotracheal tube cuff with the GlideScope in the morbidly obese patient during tracheotomy. AANA J. 2009;77:437-438.
  3. Asai T, Koga K, Vaughan RS. Respiratory complications associated with tracheal intubation and extubation. Br J Anaesth. 1998;80:767-775.
  4. Brain AI, McGhee TD, McAteer EJ, et al. The laryngeal mask airway. Development and preliminary trials of a new type of airway. Anaesthesia. 1985;40:356-361.
  5. Watcha MF, White PF, Tychsen L, et al. Comparative effects of laryngeal mask airway and endotracheal tube insertion on intraocular pressure in children. Anesth Analg. 1992;75:355-360.
  6. Brimacombe J. The advantages of the LMA over the tracheal tube or facemask: a meta-analysis. Can J Anaesth. 1995;42:1017-1023.
  7. Brain AI, Verghese C, Addy EV, et al. The intubating laryngeal mask. II: A preliminary clinical report of a new means of intubating the trachea. Br J Anaesth. 1997;79:704-709.
  8. Sinha A, Sharma B, Sood J. Pressure vs. volume control ventilation: effects on gastric insufflation with size-1 LMA. Paediatr Anaesth. 2010;20:1111-1117.
  9. Sinha M, Chiplonkar S, Ghanshani R. Pressure-controlled inverse ratio ventilation using laryngeal mask airway in gynecological laparoscopy. J Anaesthesiol Clin Pharmacol. 2012;28:330-333.
  10. Peirovifar A, Eydi M, Mirinejhad MM, et al. Comparison of postoperative complication between Laryngeal Mask Airway and endotracheal tube during low-flow anesthesia with controlled ventilation. Pak J Med Sci. 2013;29:601-605.
  11. Citerio G, Pesenti A, Latini R, Masson S, Barlera S, Gaspari F, et al. A multicentre, randomised, open-label, controlled trial evaluating equivalence of inhalational and intravenous anaesthesia during elective craniotomy. Eur J Anaesthesiol. 2012;29:371-379.
  12. Akhtar TM, McMurray P, Kerr WJ, et al. A comparison of laryngeal mask airway with tracheal tube for intra-ocular ophthalmic surgery. Anaesthesia. 1992;47:668-671.
  13. Sharma MU, Gombar S, Gombar KK, et al. Endotracheal intubation through the intubating laryngeal mask airway (LMA-Fastrach): A randomized study of LMA- Fastrach wire-reinforced silicone endotracheal tube versus conventional polyvinyl chloride tracheal tube. Indian J Anaesth. 2013;57:19-24.
  14. Eghbal MH, Sahmeddini MA. Comparison larygeal mask airway with the endotracheal tube for the external dacryocystorhionostomy surgery. A randomized clinical trial. Middle East J Anaesthesiol. 2013;22:283-288.
  15. Perelló-Cerdà L, Fàbregas N, López AM, et al. ProSeal Laryngeal Mask Airway Attenuates Systemic and Cerebral Hemodynamic Response During Awakening of Neurosurgical Patients: A Randomized Clinical Trial. J Neurosurg Anesthesiol. 2015;27:194-202.
  16. Ryu JH, Yom CK, Park DJ, et al. Prospective randomized controlled trial on the use of flexible reinforced laryngeal mask airway (LMA) during total thyroidectomy: effects on postoperative laryngopharyngeal symptoms. World J Surg. 2014;38:378-384.
  17. Cork RC, Depa RM, Standen JR. Prospective comparison of use of the laryngeal mask and endotracheal tube for ambulatory surgery. Anesth Analg. 1994;79:719-727.
  18. Denny NM, Gadelrab R. Complications following general anaesthesia for cataract surgery: a comparison of the laryngeal mask airway with tracheal intubation. J R Soc Med. 1993;86:521-522.
  19. Dyer Dyer RA, Llewellyn RL, James MF. Total i.v. anaesthesia with propofol and the laryngeal mask for orthopaedic surgery. Br J Anaesth. 1995;74:123-128.
  20. Idrees A, Khan FA. A comparative study of positive pressure ventilation via laryngeal mask airway and endotracheal tube. J Pak Med Assoc. 2000;50:333-338.
  21. Maltby JR, Beriault MT, Watson NC, et al. Gastric distension and ventilation during laparoscopic cholecystectomy: LMA-Classic vs. tracheal intubation. Can J Anaesth. 2000;47:622-626.
  22. Maltby JR, Beriault MT, Watson NC, et al. The LMA-ProSeal is an effective alternative to tracheal intubation for laparoscopic cholecystectomy. Can J Anaesth. 2002;49:857-862.
  23. Maltby JR, Beriault MT, Watson NC, et al. LMA-Classic and LMA-ProSeal are effective alternatives to endotracheal intubation for gynecologic laparoscopy. Can J Anaesth. 2003;50:71-77.
  24. Thomson KD. The effect of the laryngeal mask airway on coughing after eye surgery under general anesthesia. Ophthalmic surgery. 1992;23:630-631.
  25. Webster AC, Morley-Forster PK, Janzen V, et al. Anesthesia for intranasal surgery: a comparison between tracheal intubation and the flexible reinforced laryngeal mask airway. Anesth Analg. 1999;88:421-425.
  26. Citerio G, Pesenti A, Latini R, et al. A multicentre, randomised, open-label, controlled trial evaluating equivalence of inhalational and intravenous anaesthesia during elective craniotomy. Eur J Anaesthesiol. 2012;29:371-379.
  27. Sharma R, Dua CK, Saxena KN. A randomised controlled study comparing the effects of laryngeal mask airway and endotracheal tube on early postoperative pulmonary functions. Singapore Med J. 2011;52:874-878.
Reviews in Clinical Medicine
Volume 3, Issue 1 - Serial Number 1
January 2016
Pages 23-27

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