Removal of LMA in children.

Sir,—The article of Kitching, Walpole and Blogg 1 investigating removal of the laryngeal mask in anaesthetized and awake children merits further discussion. At our hospital we routinely use the laryngeal mask airway (LMA) in the general paediatric population for various ear, nose and throat (ENT) procedures. 2 Our standard practice is in accordance with those of both the inventor and the manufacturer of the masks. 3 The LMA is left in situ until the patient regains protective airway reflexes unless problems arise before this time requiring active airway management. We agree that children have an increased incidence of airway complications when recovering from anaesthesia compared with the adult population 4 and appreciate the challenging period this can be. For this reason we have conducted a prospective audit into the clinical use of the LMA at our hospital. As part of this we have examined specifically the recovery phase of anaesthesia with the LMA in paediatric patients. This information should add to the debate which this article will generate. Currently we have audited 140 paediatric patients aged 1–14 yr old, weighing 5–45 kg, undergoing routine ENT procedures. Anaesthesia was induced with propofol i.v. in 112 cases and sevoflurane in the remaining 28 patients. Each LMA was inserted by the classical method, as described by Brain, 3 and only reinforced masks 5 sizes 2, 2.5 and 3 were used. All were left in situ at the end of the procedure to allow full return of airway reflexes and any airway complications before or after removal of the LMA were noted. A record was also kept of who removed the mask and depth of anaesthesia on removal. A total of 126 (90%) children had a totally uneventful recovery period with no airway complications. In those cases where complications occurred, the commonest problem was either coughing or retching associated with impending mask expulsion by the patient. The overall incidence of airway complications with the LMA during recovery was as follows: seven (5%) patients coughed, four (3%) retched and three (2.5%) had laryngospasm. There were no episodes of aspiration or loss of airway. The LMA was removed by the child in 28 (22%) cases, recovery nurse in 89 (70%) cases and the anaesthetist in nine (8%) cases. None of the masks was removed at a deep stage of anaesthesia; the conscious level of the patient on removal of the LMA was recorded as light (i.e. …