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1/8/2017 Laryngealmaskairwayshavealowerriskofairwaycomplicationscomparedwithendotrachealintubation:asystematicreviewNationalLibraryof

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DatabaseofAbstractsofReviewsofEffects(DARE):QualityassessedReviews[Internet].York(UK):
CentreforReviewsandDissemination(UK)1995.

Laryngealmaskairwayshavealowerriskofairwaycomplications
comparedwithendotrachealintubation:asystematicreview
SHYuandORBeirne.
Reviewpublished:2010.

Linktofullarticle:[Journalpublisher]

CRDsummary
Thereviewconcludedthatforpatientswhoreceivedgeneralanaesthesia,useoflaryngealmaskairway
resultedinastatisticallyandclinicallysignificantlowerincidenceoflaryngospasmduringemergence,
postoperativehoarsevoiceandcoughingcomparedwithendotrachealintubation.Giventhelackofquality
assessmentandtheclinicalandmethodologicaldifferencesbetweenstudies,cautioniswarrantedwhen
interpretingtheauthorsconclusions.

Authors'objectives
Todeterminewhetherpatientswhounderwentgeneralanaesthesiaandwereprovidedwithalaryngealmask
airway(LMA)hadalowerriskofairwayrelatedcomplicationsthanthosewhounderwentendotracheal
intubation.

Searching
MEDLINE,EMBASEandTheCochraneLibraryweresearchedforarticlesinEnglishupto2009.Search
termswerereported.ThecitedreferencesearchfeatureinWebofKnowledgewasused.Referencelistsof
relevantarticlesandreviewsweresearched.

Studyselection
Randomisedcontrolledtrials(RCTs)thatcomparedLMAwithendotrachealtubeinadultpatientswho
receivedgeneralanaesthesiaforanynonemergencyelectivesurgicalprocedureconductedbyanexperienced
clinicianwereeligibleforinclusion.Trialshadtoreportonairwaycomplicationoutcomessuchashoarse
voice,laryngospasmduringemergence,regurgitation,coughing,vomiting,nausea,sorethroatandsuccessof
insertionatfirstattempt.Crossoverstudiesandstudiesoftracheotomyprocedureswereexcluded.Studieswith
inexperiencedpersonnelandstudiesthatusedtheresuscitationmodelwereexcluded.
Theincludedtrialsstudiedpatientswhounderwentvarioussurgeries(suchasbreast,cataract,
gynaecological,ophthalmic,orthopaedic,oral,peripheralandcholecystectomy).Thetypeofanaestheticused
includedenflurane,isoflurane,desflurane,sevoflurane,volatilegasandhalothane.Thetypeofventilation
wasmainlymechanicalspontaneouswasalsoreported.Sometrialsincludedfemalepatientsonly.Patient
age,wherereported,rangedfrom17to80years.AmericanSocietyofAnaesthesiologistsgraderangedfromI
toIII.
Tworeviewersindependentlyperformedstudyselection.Disagreementswereresolvedbydiscussion.

Assessmentofstudyquality
Theauthorsdidnotstatethattheyassessedstudyvalidity.

Dataextraction
Datawereextractedoncomplicationoutcomes(greatestnumberofcomplicationsatanygiventimepoint)
andusedtocalculaterelativerisks(RR)and95%confidenceintervals(CIs).
Theauthorsdidnotstatehowmanyreviewersperformeddataextraction.

Methodsofsynthesis
Fixedeffectandrandomeffectsmetaanalysiswasundertakentoobtainpooledrelativerisksand95%CIs.
StatisticalheterogeneitywasestimatedusingI2andX2.Publicationbiaswasassessedwithfunnelplots.
Sensitivityanalysisexcludedthestudywiththegreatestweightineachanalysisandonestudythatmightnot
havebeenrandomised.

Resultsofthereview
TwentynineRCTswereincludedinthereview(n=2,961patients,range20to381).
Arandomeffectsmodelshowedthatcomparedwithendotrachealtube,LMAhadstatisticallysignificantly
lowerratesoflaryngospasmduringemergence(RR3.16,95%CI1.38to7.21,I2=0%n=741),hoarsevoice

2 2
https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0030402/ 1/3
1/8/2017 Laryngealmaskairwayshavealowerriskofairwaycomplicationscomparedwithendotrachealintubation:asystematicreviewNationalLibraryof
(RR2.59,95%CI1.55to4.34,I2=1%n=457),cough(RR7.12,95%CI4.28to11.84,I2=48%n=882)and
sorethroat(RR1.67,95%CI1.33to2.11,I2=66%n=2,396).Therewasnostatisticallysignificantdifference
betweenLMAandendotrachealtubeintermsofsuccessofinsertiononfirstattempt,regurgitation,nausea
andvomiting(randomeffects).
Resultsweregenerallymoresignificantorbecamestatisticallysignificant(fornausea)whenusingthefixed
effectmodel.Exclusionofthestudywiththegreatestweightfromeachanalysisandexclusionofonestudy
thatmightnothavebeenrandomiseddidnotalterthestatisticalsignificanceofresults.Asymmetryinthe
forestplotsforcoughandsorethroatindicatedpublicationbias.

Authors'conclusions
Forpatientswhoreceivedgeneralanaesthesia,useofLMAresultedinastatisticallyandclinically
significantlylowerincidenceoflaryngospasmduringemergence,postoperativehoarsevoiceandcoughing
comparedwithendotrachealtube.

CRDcommentary
Inclusioncriteriaforthereviewwereclearlydefined.Threerelevantdatasourcesweresearched.Therewas
potentialforlanguagebias,asonlyarticlesinEnglishwereincluded.Publicationbiaswasassessedand
couldnotberuledoutforsomeoutcomes,butthereliabilityofassessingpublicationbiaswithfewerthan10
studiesislimited.Attemptsweremadetoreducereviewererrorandbiasduringstudyselectionitwasunclear
whethersuchattemptsweremadefordataextraction.Itappearedthatnoqualityassessmentwasundertaken,
whichmadethequalityoftheincludedtrialsdifficulttodetermine.Therewereclearmethodological/clinical
issueswiththeincludedstudies:somehadsmallsamplesizes,wideconfidenceintervalsforcertain
outcomes,reportednouseofanaesthesiaand/orreportedasmallnumberofeventsforoutcomessuchas
laryngospasm.Therewereotherclinicalandmethodologicaldifferencesbetweenstudies.Arandomeffects
metaanalysiswasundertakenforalltrialsandoutcomes,whichappearedmoreappropriatethanfixedeffect
giventhedifferencesinproceduresandpatients.Therewasunexplainedstatisticalheterogeneityinsome
analyses.
Giventhelackofqualityassessmentandtheclinicalandmethodologicaldifferencesbetweenstudies,caution
iswarrantedwheninterpretingtheauthorsconclusionsandrecommendations.

Implicationsofthereviewforpracticeandresearch
Practice:TheauthorsstatedthatthenumberofstudiesandconsistentresultssupporteduseofLMAfor
airwaymanagementinadultpatientswithoutairwaycompromisewhounderwentelectivesurgicalprocedure.
Research:TheauthorsstatedthatfuturestudiesthatcomparedLMAwithendotrachealtubeshouldfocuson
paediatricpatients.ComparativestudiesareneededfordifferenttypesofLMAanddifferentsurgical
procedures.Studiesshouldreportonpatientqualityoflife,surgeonratingsofeaseofsurgicalcare,
anaesthesiologistsratingsofeaseofanaesthesiacareandcostsofcaredelivery.SafetyandefficacyofLMA
inpatientswhoreceivedgeneralanaesthesiaforofficebasedoralandmaxillofacialsurgerywereneeded.

Funding
UniversityofWashingtonDentalAlumniAssociation.

Bibliographicdetails
YuSH,BeirneOR.Laryngealmaskairwayshavealowerriskofairwaycomplicationscomparedwith
endotrachealintubation:asystematicreview.JournalofOralandMaxillofacialSurgery201068(10):2359
2376.[PubMed:20674126]

OriginalPaperURL
http://dx.doi.org/10.1016/j.joms.2010.04.017

IndexingStatus
SubjectindexingassignedbyNLM

MeSH
AirwayObstruction/prevention&controlAnesthesia,Dental/instrumentation/methodsAnesthesia,
General/instrumentation/methodsHumansIntraoperativeComplications/prevention&control
Intubation,IntratrachealLaryngealMasksLaryngismus/prevention&controlRandomizedControlled
TrialsasTopicRiskSurgery,Oral/methods

AccessionNumber
12010007389

Databaseentrydate
27/07/2011

RecordStatus
https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0030402/ 2/3
1/8/2017 Laryngealmaskairwayshavealowerriskofairwaycomplicationscomparedwithendotrachealintubation:asystematicreviewNationalLibraryof

RecordStatus
ThisisacriticalabstractofasystematicreviewthatmeetsthecriteriaforinclusiononDARE.Eachcritical
abstractcontainsabriefsummaryofthereviewmethods,resultsandconclusionsfollowedbyadetailed
criticalassessmentonthereliabilityofthereviewandtheconclusionsdrawn.

CRDhasdeterminedthatthisarticlemeetstheDAREscientificqualitycriteriaforasystematicreview.
Copyright2014UniversityofYork.
PMID:20674126

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https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0030402/ 3/3

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