Risk of Complications Using Laryngeal Mask Airway vs. Endotracheal Tube During General Anesthesia in Pediatric Patients with Upper Respiratory Infections: A Narrative Review. Creation of The Upper Respiratory Infection Screening Tool© and Management Algorithm for Children Presenting for General Anesthesia with Upper Respiratory Infection ©. Megan M. Grelson RN, BSN [email protected] Capstone Project DOCTOR OF NURSING PRACTICE Primary Advisor: Mark Welliver CRNA, DNP, ARNP Secondary Advisor: Hylda Nugent CRNA, DNP, ARNP Harris College of Nursing and Health Sciences School of Nurse Anesthesia Texas Christian University DATE 2012 Word Count ABSTRACT The inflammatory process that occurs in an upper respiratory infection poses an increased risk of complications for children undergoing general anesthesia for a surgical procedure. For the last 20 years, the increased risk for complications has resulted in providers postponing surgical procedures. Today, surgeons are able to proceed with these surgical procedures because of advanced airway management techniques. Anesthesia professionals now have the additional option of using a laryngeal mask airway in addition to intubation or cancelation. The question that arises is; which airway device is better and carries less risk of adverse respiratory complications, laryngeal mask airways or endotracheal tubes, in pediatric patients with upper respiratory infections requiring anesthesia for surgery. The literature was searched using Embase, CINAHL, and The Cochrane Library for articles comparing the use of laryngeal mask airways and endotracheal tubes in children with upper respiratory infections. Findings include laryngeal mask airways have a decreased risk of complications when compared to endotracheal tubes when used in children with upper respiratory infections. Laryngeal mask airways should be considered in place of endotracheal tubes in children with upper respiratory infections undergoing general anesthesia. A Upper Respiratory Infection Screening Tool was designed to provide quick recognition of children at high risk for complications associated with upper respiratory infection. Additionally A Management Algorithm for Children Presenting for General Anesthesia with Upper Respiratory Infections was developed to guide anesthesia professionals in determining whether to postpone a general anesthetic or proceed with an endotracheal tube verses laryngeal mask airway in pediatric patients with upper respiratory infections. A continuing educational course for the American Association of Nurse Anesthetists Journal was developed to distribute 1 this information. The ACE Star Model was the guiding framework used to implement this evidence-based clinical guide 2 PART ONE: Introduction and Overview Methodology Introduction Upper respiratory infections (URIs) are the most common illnesses among children, with most children developing 6-10 URIs a year.1 These infections can be caused by more than 200 different viruses, the most common being the rhinovirus.1 Children can contract any URI causing virus through droplets in the air or from direct contact with someone who is ill.1 Children are more susceptible to the illness due to their immature immune systems and close contact with other children in schools and daycares.1 The most common symptoms of URIs are runny nose, cough, congestion, sore throat, and low grade fever. A complete list of symptoms can be found in Table 1. Upper respiratory infections are so common in children, their URI may be present when the child is scheduled for surgery. In 1979, McGill et al were the first to conclude that there is an increased risk of respiratory complications in children with recent URIs who undergo general anesthesia.2 The infection causes an acute inflammatory process that results in hyper-reactivity of the airway smooth muscle that can last anywhere from 4 to 6 weeks.3,4,5 Since this observation, anesthesia providers have disagreed as to whether a child should undergo an elective surgical procedure or if it should be postponed or even canceled, allowing more time for the child to recover from their URI. The problem with waiting is by the time 4 to 6 weeks pass, the child usually has acquired a new URI. The belief was that children with recent or current URIs were at an increased risk of peri- and post-operational complications including laryngospasm, bronchospasm, oxygen desaturation.3,4,5,6,7,8,9,10 (see Table 2) In 1991, Cohen and Cameron published the largest prospective observational study involving 1,283 children with URIs and 20,876 without.11 Their 3 research found that children presenting with URIs were two to seven times more likely to have respiratory complications peri- and postoperatively.11 Upper respiratory infections increase the risk for complications in children, as seen in Table 2. The infection causes an acute inflammatory process that results in hyper-reactivity of the airway smooth muscle that can last anywhere from 4 to 6 weeks.3,4,5 Anesthetic gases and airway manipulation can irritate the already hyper-reactive smooth muscle, causing an increased risk of bronchoconstriction and laryngospasm in the child.3,4,5 An important part of the anesthesia provider’s tasks is to avoid stimulation of the larynx in the already sensitive airway, therefore decreasing the likeliness of laryngospasms, bronchospasms and/or bronchoconstriction.3 Different invasive airway devices Several different types of airway devices can be used during a general anesthetic to provide the patient the ability to spontaneous breathe to provide positive pressure ventilation either mechanically by the ventilator or manually by the provider. The airway device is directly connected to the breathing circuit on the anesthesia machine to deliver carrier gasses to the patient. An endotracheal tube (ETT) is “a large-bore catheter inserted through the mouth or nose and into the trachea to a point above the bifurcation of the trachea. It is used for delivering oxygen and other gases at or above atmospheric pressure.”12 Endotracheal tubes were the primary means of facilitating mechanical ventilation of patients for decades, and are still the primary means of securing an airway. Laryngeal mask airways (LMAs) were first approved by the U.S. Food and Drug Administration in 1991, and have since been used as a passive and positive-pressure ventilating device in surgeries.13 They are a slightly less invasive way to provide an airway in patients 4 undergoing general anesthesia and have been gaining in popularity. Laryngeal mask airways are “inserted blindly into the pharynx, forming a low-pressure seal around the laryngeal inlet and permitting spontaneous or gentle positive-pressure ventilation.”13 Debate has begun regarding what method of airway management has the least laryngeal stimulation and lowest risk of complications to the patient.6 Current research is attempting to determine which airway device, an ETT or LMA, is better for use in children with a current or recent URI undergoing general anesthesia. Overview Methodology Institutional Review Board (IRB) Approval from the Texas Christian University IRB was requested for this TCU systematic review project in October 2011. Approval from the IRB board was granted December 2011 as shown in Appendix 1. Data Collection A literature search was conducted using Embase, CINAHL, and The Cochrane Library to find articles comparing the use of ETTs and LMAs in pediatric patients with recent or current URIs undergoing general anesthesia. The keywords used were “anesthes*,” “surgery,” “pediatric*,” “child*,” “respiratory infection,” “upper respiratory infection,” “ETT,” “endotracheal tube,” “LMA,” and “laryngeal mask airway.” Keywords were combined using OR and AND to limit the results. The final search was ran as “(anesthes* OR surgery) AND (pediatric* OR child) AND (“respiratory infection” OR “upper respiratory infection”) AND (ett OR “endotracheal tube” OR lma OR “laryngeal mask airway”).” One hundred thirty-one abstracts were reviewed with eight relevant articles found. The reference lists from the eight studies were reviewed finding an additional two articles meeting inclusion criteria. This search 5 was conducted in October 2010, and repeated in May 2011, September 2011, November 2011, February 2012, and March 2012 with the same articles found on each search. Inclusion/Exclusion Criteria In order to be included in this literature review, articles had to compare ETTs and LMAs used in pediatric patients undergoing general anesthesia with a recent or current URI. The studies had to compare ETTs and LMAs to determine which airway device had the higher incidence of complications. Editorial or opinion pieces were included, but the clinical guidelines provided in this synthesis were not made based on opinion pieces. Studies including adults in the studied population were excluded in this literature review. Any study that excluded children with recent or current URIs was excluded. If only one airway device (LMA or ETT) was studied, the article was excluded from the literature review. Levels of Evidence Each article was compared to the Joanna Briggs Institute Levels of Evidence (LOE) rating system (Table 3).14 After reading the articles, a score from 1 to 4 was given based on the characteristics of the article content. The LOE rating of each article can be seen in Table 4. 6 PART TWO: Literature Background For the past 20 years, surgeries had been postponed for children with current or recent URIs.3,4,6,7 More recently, research has suggested that anesthesia can still be safely provided to children with careful planning.3,4,5,6,7,8,9,10,15,17 Anesthesia providers have the responsibility of selecting the right plan of care for each individual patient based on the type of procedure they are having and their health history. Airway management is one of the decisions made by the anesthesia provider and can be a critical decision when a patient has a current or recent URI. Anesthesia providers need to choose between the different airway devices for the most optimal device, ETT or LMA, for the patient. Review of Literature Although there is a sufficient amount of research available on children with recent or current URIs undergoing anesthesia, there is not much research on what is the best airway device to use in those patients, an ETT or LMA. The only level 1 article in this literature review was the study by Tartari et al. This randomized control trial (RCT) consisted of 400 patients between the ages 6 months and 12 years.10 The subjects were assigned to either the LMA or ETT group and within those groups it was determined whether or not the child had an URI.10 This study determined that adverse respiratory events were more frequent in children with an URI when compared to children without an URI.10 Children with URIs had more adverse respiratory events including laryngospasm, stridor, and excessive coughing, when an ETT was used compared to an LMA. This study advocates the use of LMAs over the use of ETTs in children with URIs.10 In the RCT performed by Wakhloo et al, 40 patients with clear rhinorrhoea and mild cough only were included in the study.4 There was random assignment to two different groups, 7 the ETT or LMA group, based on what airway device was used during their surgical procedures.4 This study found less oxygen desaturation, bronchospasm, and laryngeal stimulation in the LMA group as compared to the ETT group and an increased risk of postoperative complications when using an ETT.4 In the 1998 study performed by Tait et al, 82 patients with URIs who were eligible to use either LMA or ETT in their surgery were included in the study and were randomly assigned to one of these airway devices.6 Both of the studies by Wakhloo et al and Tait et al found that LMAs had more advantages and fewer respiratory related complications than ETTs.4,6 The advantages of using an LMA are decreased incidence of laryngospasm, sore throat and bronchospasm.4,6 The complications seen with the ETT group were coughing, sore throat, laryngospasm, bronchospasms, arterial oxygen desaturation, and breath-holding.4,6 Tait and Malviya’s 2005 study was a literature review that compared nine different studies, all of which studied the complications caused by recent or current URIs in children undergoing anesthesia.3 When comparing ETTs and LMAs, this study concluded that LMAs were associated with fewer adverse respiratory events than ETTs.3 Another literature review written by Höhne et al came to the conclusion that LMAs should be used in children with URIs undergoing anesthesia.15 Höhne et al recommend waiting four weeks after an URI for elective surgeries if possible to allow healing.15 If the surgery cannot be postponed, LMAs should be used in those children rather than ETTs due to the decreased risk of complications.15 Parnis et al’s 2001 observational survey of practice study showed that LMAs provide a safe and non-irritating airway to patients with a decreased risk of adverse reactions when compared to ETTs.8 Homer et al’s 2007 study used data from several prospective observational and interventional studies to come up with their conclusions that LMAs have an increased amount of respiratory complications when compared to ETTs.7 8 Flick et al’s 2008 retrospective study went through the medical records of 130 pediatric patients who had experienced a laryngospasm during anesthesia.16 This study found that LMAs had an increased risk of laryngospasm when compared to ETTs in children with URIs.16 It was not clear what caused the increase risk of laryngospasm with LMAs, but it was thought to be the accumulation of secretions in the airway during emergence.16 Eikermann wrote an editorial in response to a study by von Ungern-Sternberg where LMAs were used in children with and without current or recent URI symptoms.5,9 Von Ungern- Sternberg’s study found an increased risk of respiratory complications when LMAs were used in children who had URIs, and a lower risk of adverse respiratory complications in those without recent URIs.5 Eikermann argued that children with recent URIs were more likely to have adverse respiratory reactions with ETTs rather than with LMAs.9 Eikermann claimed that, in his experience, LMAs were a better choice of airway protection and had a lower risk of complications.9 In reply to the editorial, von Ungern-Sternberg defended his claim by writing that LMAs being used in children with URIs have an increased risk of complications.17 Both authors agreed that more RCTs need to be conducted to come to provide a clearer position on what airway device has the decreased risk of complications.9,17 Both von Ungern-Sternberg and Eikermann agreed, that children without URI symptoms in the previous 2 weeks could be safely anesthetized without an increased risk of respiratory complications.5,9 Discussion Eight studies have explored whether LMAs or ETTs have an increased risk of adverse reactions when used in children with recent or current URIs. An additional two editorials discuss the use of LMAs and ETTs in children with recent or current URIs. 9