Risk factors for difficult Laryngeal Mask Airway LMA-Supreme™ (LMAS) placement in adults: A multicentric prospective observational study in an Italian population

BACKGROUND: Supraglottic airway devices (SADs) are precious tools for airway management in both routine and rescue situations; few studies have analyzed the risk factors for their difficult insertion. METHODS: The aim of this study was to identify the risk factors for difficult insertion for a specific SAD, the Laryngeal Mask Airway LMA-Supreme™ (LMAS). This was a prospective multicentric observational study on a cohort of Italian adult patients receiving general anesthesia for elective surgery. The possible causes of difficulty in LMAS placement (difficulty in insertion or unsatisfactory ventilation) were identified based on literature and on the opinion of international airway management experts. A dedicated datasheet was prepared to collect patients’ data, including anthropometric-parameters and parameters for the prediction of difficult airway management, as well as technical choices for the use of LMAS. Data were analyzed to discover the risk factors for difficult LMAS placement and the association between each risk factor and the proportion of incorrect positioning was evaluated through the relative risk and its confidence interval. RESULTS: Four hundred thirty-two patients were enrolled; seventy required two or more attempts to insert the LMAS; nine required a change of strategy. At multivariate analysis, the following factors were significantly associated with difficult LMAS placement: Mallampati III-IV with either phonation or not; inter-incisor distance < 3 cm; reduced neck mobility; no administration of neuromuscular blocking agents (NMBAs). CONCLUSIONS: The alignment of the laryngeal and pharyngeal axes seems to facilitate the procedure, together with NMBA administration; on the contrary, Mallampati grade III-IV are associated with difficult LMAS placement.