Original Article Yonsei Med J 2016 Jul;57(4):987-997 http://dx.doi.org/10.3349/ymj.2016.57.4.987
pISSN: 0513-5796 · eISSN: 1976-2437
Standard versus Rotation Technique for Insertion of Supraglottic Airway Devices: Systematic Review and Meta-Analysis Jin Ha Park, Jong Seok Lee, Sang Beom Nam, Jin Wu Ju, and Min-Soo Kim Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Purpose: Supraglottic airway devices have been widely utilized as an alternative to tracheal intubation in various clinical situations. The rotation technique has been proposed to improve the insertion success rate of supraglottic airways. However, the clinical efficacy of this technique remains uncertain as previous results have been inconsistent, depending on the variable evaluated. Materials and Methods: We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials in April 2015 for randomized controlled trials that compared the rotation and standard techniques for inserting supraglottic airways. Results: Thirteen randomized controlled trials (1505 patients, 753 with the rotation technique) were included. The success rate at the first attempt was significantly higher with the rotation technique than with the standard technique [relative risk (RR): 1.13; 95% confidence interval (CI): 1.05 to 1.23; p=0.002]. The rotation technique provided significantly higher overall success rates (RR: 1.06; 95% CI: 1.04 to 1.09; p100 insertions by standard technique
4.35 (3.71)
Jeon, et al.21
Ghai, et al.
Classic
No in standard group, yes in rotation group
First-attempt and overall success rate of insertion, insertion time, fiberoptic grade, blood on the removed device, maneuvers used to relieve airway obstruction, laryngospasm, desaturation
>100 LMA insertions in children
Children aged 78 to standard 2.5 months 78 to 180° rotation to 10 yrs (crossover)
1, 1.5, 2, 2.5
20
No
First-attempt and overall success rate of insertion, insertion time, OLP, blood on the removed device, sore throat and hoarseness on the day of surgery
>50 Proseal insertions in children
6 (2) 6 (2)
63 to standard 63 to 90° rotation
Children aged 3 to 9 yrs
2, 2.5, 3
Proseal
Yun, et al.6
3, 4
No
No
First-attempt and overall success rate of insertion, insertion time, blood on the removed device, laryngospasm, desaturation
>200 LMA insertions in adults
41.68 (14.07) 39.88 (14.24)
50 to standard 50 to 180° rotation
Adults
-
Classic
Adults
First-attempt and overall success rate of insertion, insertion time, manipulation required, OLP, fiberoptic grade, blood on the removed device, sore throat at the day of surgery and the next day
>300 i-gel insertions
65.2 (10.8) 66.6 (9.0)
91 to standard 90 to 90° rotation
Cuff inflation before insertion
Outcomes
Experience of device provider
Age (yr)
Number of patients per group
Participants
Kumar, et al.8
3, 4
Airway size
i-gel
Airway & size
Kim, et al.5
Trials
Table 1. Characteristics and Outcomes of Randomized Controlled Trials Included in the Meta-Analysis
No
No
No
Sch
Yes
No
Yes
No
Yes
Use of NMB
Insertion Technique for Supraglottic Airways
http://dx.doi.org/10.3349/ymj.2016.57.4.987
Classic
Classic
Soh and Ng13
Brimacombe and Berry16
http://dx.doi.org/10.3349/ymj.2016.57.4.987
NMB, neuromuscular blocking drug; OLP, oropharyngeal leak pressure; LMA, laryngeal mask airway; Sch, succinylcholine; SD, standard deviation. Values are number and mean (SD).
No No Overall success rate of insertion, fiberoptic grading, blood on the removed device, sore throat and hoarseness on the next day >500 LMA insertions with experience of both technique
Classic Nakayama, et al.12
3, 4
Adults
30 to standard 30 to 180° rotation
54 (24) 53 (21)
No No Overall success rate of insertion, fiberoptic grading, blood on the removed device 1.5, 2, 2.5, 3
Experienced provider Children aged 31 to standard 1 to 15 yrs 36 to 180° rotation
2
5.04 5.41
No Yes 3.0 (1.6) 3.0 (1.3) Children aged 75 to standard 10 months to 70 to 180° rotation 7 yrs
Insertion experience only by standard technique
First-attempt and overall success rate of insertion, insertion time, blood on the removed device, maneuvers used to relieve airway obstruction, laryngospasm, desaturation
Unknown Unknown Overall success rate of insertion, insertion time, blood on the removed device Unknown 2.93 (1.34) 3.0 (1.13) Children using 40 to standard Proseal size 2 40 to 180° rotation Proseal Watanabe, et al.15
2
Experience of device provider Age (yr) Number of patients per group Participants Airway size Airway & Size Trials
Table 1. Characteristics and Outcomes of Randomized Controlled Trials Included in the Meta-Analysis (Continued)
Outcomes
Cuff inflation before insertion
Use of NMB
Jin Ha Park, et al.
formed using the results of ten studies reporting insertion time as a continuous variable. When using the rotation technique, device insertion was established more rapidly (MD: -4.6 seconds; 95% CI: -7.37 to -1.74; p=0.002; I2=95%; D-L random) (Fig. 4). A subgroup analysis of four studies with 90-degree rotation resulted in a greater MD yet similar heterogeneity (MD: -6.49 seconds; 95% CI: -10.97 to -2.01; p=0.005; I2=84%; D-L random).5,6,10,21 A subgroup analysis of five adult studies showed similar results (MD: -6.14 seconds; 95% CI: -10.65 to -1.63; p=0.008; I2=93%; D-L random).5,9,10,14,21 However, we did not know differences in insertion time during subgroup analyses involving 180-degree rotation7,9,12,14,15,20 and children.6,7,12,15,20 In addition, the substantial heterogeneity of the pooled results was not resolved via sensitivity analyses. The incidence of manipulations required for successful insertion was reported in two studies involving 90-degree rotation and adults;5,10 however, we did not know a decrease in the incidence in the rotation technique (RR: 0.59; 95% CI: 0.34 to 1.05; p=0.074; I2=54%; M-H random). Blood staining on the airway device at removal was investigated in 12 studies.5-10,12-15,20,21 One additional study16 evaluated the presence of blood via fiberoptic visualization, and their results were included in the pooled analysis. The incidence of blood staining using the rotation technique was significantly lower than that observed with the standard technique (RR: 0.36; 95% CI: 0.27 to 0.47; p
pISSN: 0513-5796 · eISSN: 1976-2437
Standard versus Rotation Technique for Insertion of Supraglottic Airway Devices: Systematic Review and Meta-Analysis Jin Ha Park, Jong Seok Lee, Sang Beom Nam, Jin Wu Ju, and Min-Soo Kim Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
Purpose: Supraglottic airway devices have been widely utilized as an alternative to tracheal intubation in various clinical situations. The rotation technique has been proposed to improve the insertion success rate of supraglottic airways. However, the clinical efficacy of this technique remains uncertain as previous results have been inconsistent, depending on the variable evaluated. Materials and Methods: We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials in April 2015 for randomized controlled trials that compared the rotation and standard techniques for inserting supraglottic airways. Results: Thirteen randomized controlled trials (1505 patients, 753 with the rotation technique) were included. The success rate at the first attempt was significantly higher with the rotation technique than with the standard technique [relative risk (RR): 1.13; 95% confidence interval (CI): 1.05 to 1.23; p=0.002]. The rotation technique provided significantly higher overall success rates (RR: 1.06; 95% CI: 1.04 to 1.09; p100 insertions by standard technique
4.35 (3.71)
Jeon, et al.21
Ghai, et al.
Classic
No in standard group, yes in rotation group
First-attempt and overall success rate of insertion, insertion time, fiberoptic grade, blood on the removed device, maneuvers used to relieve airway obstruction, laryngospasm, desaturation
>100 LMA insertions in children
Children aged 78 to standard 2.5 months 78 to 180° rotation to 10 yrs (crossover)
1, 1.5, 2, 2.5
20
No
First-attempt and overall success rate of insertion, insertion time, OLP, blood on the removed device, sore throat and hoarseness on the day of surgery
>50 Proseal insertions in children
6 (2) 6 (2)
63 to standard 63 to 90° rotation
Children aged 3 to 9 yrs
2, 2.5, 3
Proseal
Yun, et al.6
3, 4
No
No
First-attempt and overall success rate of insertion, insertion time, blood on the removed device, laryngospasm, desaturation
>200 LMA insertions in adults
41.68 (14.07) 39.88 (14.24)
50 to standard 50 to 180° rotation
Adults
-
Classic
Adults
First-attempt and overall success rate of insertion, insertion time, manipulation required, OLP, fiberoptic grade, blood on the removed device, sore throat at the day of surgery and the next day
>300 i-gel insertions
65.2 (10.8) 66.6 (9.0)
91 to standard 90 to 90° rotation
Cuff inflation before insertion
Outcomes
Experience of device provider
Age (yr)
Number of patients per group
Participants
Kumar, et al.8
3, 4
Airway size
i-gel
Airway & size
Kim, et al.5
Trials
Table 1. Characteristics and Outcomes of Randomized Controlled Trials Included in the Meta-Analysis
No
No
No
Sch
Yes
No
Yes
No
Yes
Use of NMB
Insertion Technique for Supraglottic Airways
http://dx.doi.org/10.3349/ymj.2016.57.4.987
Classic
Classic
Soh and Ng13
Brimacombe and Berry16
http://dx.doi.org/10.3349/ymj.2016.57.4.987
NMB, neuromuscular blocking drug; OLP, oropharyngeal leak pressure; LMA, laryngeal mask airway; Sch, succinylcholine; SD, standard deviation. Values are number and mean (SD).
No No Overall success rate of insertion, fiberoptic grading, blood on the removed device, sore throat and hoarseness on the next day >500 LMA insertions with experience of both technique
Classic Nakayama, et al.12
3, 4
Adults
30 to standard 30 to 180° rotation
54 (24) 53 (21)
No No Overall success rate of insertion, fiberoptic grading, blood on the removed device 1.5, 2, 2.5, 3
Experienced provider Children aged 31 to standard 1 to 15 yrs 36 to 180° rotation
2
5.04 5.41
No Yes 3.0 (1.6) 3.0 (1.3) Children aged 75 to standard 10 months to 70 to 180° rotation 7 yrs
Insertion experience only by standard technique
First-attempt and overall success rate of insertion, insertion time, blood on the removed device, maneuvers used to relieve airway obstruction, laryngospasm, desaturation
Unknown Unknown Overall success rate of insertion, insertion time, blood on the removed device Unknown 2.93 (1.34) 3.0 (1.13) Children using 40 to standard Proseal size 2 40 to 180° rotation Proseal Watanabe, et al.15
2
Experience of device provider Age (yr) Number of patients per group Participants Airway size Airway & Size Trials
Table 1. Characteristics and Outcomes of Randomized Controlled Trials Included in the Meta-Analysis (Continued)
Outcomes
Cuff inflation before insertion
Use of NMB
Jin Ha Park, et al.
formed using the results of ten studies reporting insertion time as a continuous variable. When using the rotation technique, device insertion was established more rapidly (MD: -4.6 seconds; 95% CI: -7.37 to -1.74; p=0.002; I2=95%; D-L random) (Fig. 4). A subgroup analysis of four studies with 90-degree rotation resulted in a greater MD yet similar heterogeneity (MD: -6.49 seconds; 95% CI: -10.97 to -2.01; p=0.005; I2=84%; D-L random).5,6,10,21 A subgroup analysis of five adult studies showed similar results (MD: -6.14 seconds; 95% CI: -10.65 to -1.63; p=0.008; I2=93%; D-L random).5,9,10,14,21 However, we did not know differences in insertion time during subgroup analyses involving 180-degree rotation7,9,12,14,15,20 and children.6,7,12,15,20 In addition, the substantial heterogeneity of the pooled results was not resolved via sensitivity analyses. The incidence of manipulations required for successful insertion was reported in two studies involving 90-degree rotation and adults;5,10 however, we did not know a decrease in the incidence in the rotation technique (RR: 0.59; 95% CI: 0.34 to 1.05; p=0.074; I2=54%; M-H random). Blood staining on the airway device at removal was investigated in 12 studies.5-10,12-15,20,21 One additional study16 evaluated the presence of blood via fiberoptic visualization, and their results were included in the pooled analysis. The incidence of blood staining using the rotation technique was significantly lower than that observed with the standard technique (RR: 0.36; 95% CI: 0.27 to 0.47; p
