PROJECT PROPOSAL

COMPARING TWO METHODS OF LARYNGEAL MASK AIRWAY INSERTION CLASSIC VERSUS SIMPLIFIED (LARYNGO SCOPY AIDED)

Dr. R. Muralidharan
Assistant Professor in Anaesthesiology

Department of Anaesthesiology, Medical College, Thiruvananthapuram

INTRODUCTION LMA has become a common alternative in airway management. This device works as a supraglottic airway manager which is placed close to the larynx to let spontaneous or controlled ventilation with airway pressures more than 15-20mmHg
(1,2,3,4,6) (5)

. LMA can also be applied in prone and lateral position

LMA has been used for Ophthalmological procedures. Studies have shown that intra ocular pressure is lower during induction, maintenance and emergence when LMA is used compared to a tracheal intubation. Intra ocular pressure remains lower during recovery from Anaesthesia with a LMA. It is essential to prevent coughing especially in cases of open globe injuries. Moreover it has been used as primary airway in Pierre Robin and Treacher Collins Syndromes. In case of dacryocysto rhinostomy and probing of the nasolacrimal duct, LMA cuff acts as a throat pack that prevents aspiration of blood and secretions.
(6, 8)

LMA appears to offer better protection than cuffed or uncuffed tracheal tube for the above type of surgeries. As there is no intrusion of lower airway in LMA placement so chances of infection is low. LMA offers may other advantages like head may be turned without loss of airway LMA can be used in children and infants and it may be particularly helpful in children in whom unusual anatomy makes tracheal intubation difficult. In Ophthalmic surgeries like lens aspiration of congenital cataract the patients may have higher chance of getting anatomical variations in airway as in the case of Treacher Collins and Pierre Robin syndrome which are prevalent in Ophthalmic procedures. LMA can maintain satisfactory airway with fewer adverse respiratory effects. LMA allows smoother awakening than a tracheal tube with fewer episodes of desaturation, coughing and laryngospasm. Emergence and recovery time are also shorter. Patients who have had an LMA required less analgesia during recover. All these are essential components of ophthalmic procedures in order to prevent rise in intra ocular pressure during intra operative and post operative period. An outstanding feature of LMA is that

it can be used more successfully if used in an appropriate way in managing the airway both in controlled and spontaneously breathing patients. There are several methods of inserting LMA. None of them are considered as definite one but all are found to decrease the complication. success rate is 67-90%.
(2,3,11) (7, 8, 9, 10)

. In

standard method of inserting LMA the cuff is empty and the first attempt .

A little inflation of cuff is useful in LMA passing through the Posterior Pharyngeal arch and eases the insertion resulting in higher success rate. Here the LMA is positioned in midline and while having direct contact with the patients hard palate and proceeded forward into the posterior pharyngeal space via soft palate with the help of pressure applied upward against the hard palate till LMA tip reaches the upper oesophageal sphincter.
(2,3,4,7,8)

We were following the above methods for a long time with a number of failures of insertion and injury to tonsil in many of our patients which are mostly from paediatric age group, so as to avoid injury and failure of insertion, we in this study inserted LMA after doing a gentle direct laryngoscopy in order to swipe the tongue to the left and visualise the injury prone structures like tonsil and floppy epiglottis. LMA is inserted through the angle of mouth and brought back to midline and pushed until the resistance is felt. (Series of photos Attached). This method was practised as a pilot study in more than 20 cases and was demonstrated as an easier method with fewer complications besides not having those problems such as finger entrance to the mouth, contact with patients teeth, injury to tonsils, bleeding which occurs often with the standard technique.

AIM Study is aimed at comparing two methods of Laryngeal mask airway insertion in Paediatric age group. OBJECTIVE

To compare the advantages of simplified method of Laryngeal mask airway insertion to Classic method of Laryngeal mask airway insertion.

METHODOLOGY 1. Study Design: Comparitive Study 2. Setting: Department of Anaesthesiology, Regional Institute of

Ophthalmology, Thiruvananthapuram. 3. Study Population: Patients undergoing various ophthalmic surgeries posted electively as well as emergency in the age group 1-10 years.

INCLUSION CRITERIA 1. American Society of Anaesthesiologists Physical Status (ASAPS) 1 and 2. 2. Age group 1-10 years 3. Cataract surgery, squint surgery and open globe injuries requiring general anesthesia.

EXCLUSION CRITERIA 1. Children of those parents who are not giving written consent.

2. Amerian Society of Anaesthesiologists Physical Status (ASAPS) 3 and 4. SAMPLE SIZE CALCULATION We assumed that the time taken for successful placement of LMA by classic method will be twice that of simplified method . From the literature, in the classic method of inserting LMA usually the cut off is empty and the first attempt success rate is 67- 90 %
(2, 3

). With an = 0.05, two tailed and a

power of 80%, we need 55 patients per group, hence a total of 110 patients will be included in this study.

STATISTICAL ANALYSIS The distribution of various factors amongst the classic group compared to the Simplified group and the differences will be tested using the Chi-square statistic (the Fisher exact test will be used if the expected value of a cell was less than 5) for categorical data. We can use the two-sided independent Students t-tests to analyze continuous data, the MannWhitney U-test for ordinal data. STUDY PERIOD 1 Year PROCEDURE After getting approval from Research and ethical committee of Medical College Thiruvananthapuram, The study will be conducted in the Department of Anaesthesiology, Regional Instoitute of Ophthalmology, Thiruvananthapuram. Patients in the age group 1-10 years is included in the study as surgical procedures need not be done under General Anaesthesia for those above 10 years.

Children will be randomly allocated into two groups to undergo Classic and simplified LMA insertion method. All study subjects will be selected on admission basis for elective and emergency surgeries until sample size is met. Advantage of each procedure will be measured using a scoring system taking into account the number of attempts taken for successful insertion, duration of time for successful insertion, presence or absence of blood on LMA, gastric insufflations, leaks around cuff and increase in intraocular pressure.

PROFORMA
Personal Details 1. Sl.No. 2. Date of Surgery: 3.IP No:

4. Name: _______________________________________________________________ 5. Age: 7. Address: 6. Sex:

(1. Male, 2. Female)

_________________________________________________________ _________________________________________________________

8. Study Group:

(1. Classic Group, 2. Simplified Group)

9. History: _________________________________________________________ Pre-OP Examination 10. HR: 13. ASA PS: 11. BP: (1, 2, 3, 4) / 12. Weight:
(1. Pallor, 2. Icterus, 3. Cyanosis, 4. Clubbing)

14. General Exam:

15. CVS_______________________16. RESP ________________________ 17. GIT _______________________18. CNS _________________________ 19. Diagnosis: _________________________________________________________

20. Type of Surgery: ______________________________ 21. Time: _______________ 22. Induction: _________________________________________________________ 23. Medicine: 24. Size LMA: Scoring System 25. Number of Attempts: 26. Duration of time for successful insertion (sec): 27. Blood on laryngeal mask airway: 28. Gastric insufflations:
(1. Yes, 2. No) (1. Fentanyl, 2. Propofol, 3. Xylocaine)

(a. 1 , b. 2, c. 2 )

(a. 1, b. 2, c. 3) (a. <10, b. 10-15, c. >15)

(1. Yes, 2. No) 29. Leak

around cuff:

(1. Yes, 2. No)

30. Increase in intraocular pressure: 31. Procedure:

(1. Yes, 2. No) (1. Poor, 2. Good)