The Safety of the Laryngeal Mask Airway in Adenotonsillectomy: A Systematic Review and Meta-Analysis

Abstract

Background: Adenotonsillectomy is one of the most common surgical procedures worldwide. The current standard for securing the airway in patients undergoing adenotonsillectomy is endotracheal tube (ETT) intubation. Several studies have investigated the use of the laryngeal mask airway (LMA) in this procedure. We conducted a systematic review and meta-analysis to compare the safety and efficacy of the LMA versus ETT in adenotonsillectomy.

Method: Databases were searched from inception to 2022 for randomized controlled trials and comparative studies. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The primary outcome is the rate of perioperative respiratory adverse events (PRAEs). Secondary outcomes included the rate of conversion to ETT, desaturations, nausea/vomiting, and surgical time. A subgroup analysis, risk of bias, publication bias, and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessments were also performed.

Results: Twelve studies were included in the analysis (4176 patients). The mean overall conversion to ETT was 8.36% [95% confidence interval (CI) = 8.17, 8.54], and for the pediatric group 8.27% (95% CI = 8.08, 8.47). The mean rate of conversion to ETT secondary to complications was 2.89% (95% CI = 2.76, 3.03) while the rest was from poor surgical access. Overall, there was no significant difference in PRAEs [odds ratio (OR) 1.16, 95% CI = 0.60, 2.22], desaturations (OR 0.79, 95% CI = 0.38, 1.64), or minor complications (OR 0.89, 95% CI = 0.50, 1.55). The use of LMA yielded significantly shorter operative time (mean difference -4.38 minutes, 95% CI = -8.28, -0.49) and emergence time (mean difference -4.15 minutes, 95% CI = -5.63, -2.67).

Conclusion: For adenotonsillectomy surgery, LMA is a safe alternative to ETT and requires less operative time. Careful patient selection and judgment of the surgeon and anesthesiologist are necessary, especially given the 8% conversion to ETT rate.

Keywords: LMA; adenotonsillectomy; airway management; endotracheal tube; laryngeal mask airway; meta-analysis; pediatric adenotonsillectomy; pediatric anesthesia; postoperative outcomes; systematic review.

Graphical abstract

Figure 1.

PRISMA flow diagram for study selection using Covidence. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2.

(a) Forest plot comparing the total number of PRAEs between the LMA and ETT as an odds ratio. The peds group includes only pediatric patients and the mixed group includes both pediatric as well as adult patients. (b) Forest plot comparing the total number of PRAEs between the LMA and ETT as an odds ratio excluding the data from the study by Williams 1993. The peds group includes only pediatric patients and the mixed group includes both pediatric as well as adult patients. (c) Conversion rate from LMA to ETT shown as a percentage of all intubations in the total group as well as the pediatric group. The error bars represent the standard deviation. (d) Forest plot comparing the total number of minor complications between the LMA and ETT as an odds ratio. (e) Forest plot comparing the total number of desaturations between the LMA and ETT as an odds ratio. The peds group includes only pediatric patients and the mixed group includes both pediatric as well as adult patients. (f) Forest plot comparing the intubation time between LMA and ETT. (g) Forest plot comparing the extubation time between LMA and ETT. (h) Forest plot comparing the total operative time between LMA and ETT. PRAE, perioperative respiratory adverse events; LMA, laryngeal mask airway; ETT, endotracheal tube.