Effects of laryngeal mask airway removal under different anesthesia states on pediatric airway complications: a systematic review and meta-analysis
TL;DR
This meta-analysis suggests awake LMA removal is associated with lower airway obstruction risk than deep removal, which primarily reduces secretions, and risk-stratified protocols are suggested if deep removal is performed.
Abstract
Objective This meta-analysis was designed to compare airway complication rates between deep vs. awake laryngeal mask airway (LMA) removal in pediatric non-airway surgery, while discussing the impact of anesthetic agents, patient position and age. Methods We systematically searched PubMed, Web of Science, and Cochrane Library to identify studies meeting the inclusion criteria. The primary outcome measured was the incidence of overall airway complications, which included laryngospasm, airway obstruction, desaturation, breath-holding, cough, and excessive secretions. Secondary outcomes included subgroup analyses stratified by patient positioning during LMA removal, inhalational anesthetic agents and age. Results Pooled analysis of 10 randomized controlled trials (RCTs) (n = 1,713) revealed no significant difference in overall airway complications (relative risk (RR) of 0.93, 95% confidence interval (CI) [0.65–1.32], p = 0.68) or specific outcomes (laryngospasm, desaturation, breath-holding, cough) between deep and awake LMA removal; however, deep removal was associated with a significantly higher airway obstruction risk and a lower incidence of excessive secretions. Subgroup analyses demonstrated that inhalational anesthetic agents type (sevoflurane/isoflurane) did not alter most complications but universally increased airway obstruction risk, whereas positioning during deep removal reduced secretions in both lateral/supine positions yet increased obstruction, with lateral positioning uniquely lowering desaturation risk. Notably, age did not modulate the airway obstruction risk profile: children under 6 years and over 6 years exhibited comparably elevated obstruction risks with deep removal. Conclusions This meta-analysis suggests awake LMA removal is associated with lower airway obstruction risk than deep removal, which primarily reduces secretions. Given the higher clinical severity of obstruction, clinicians may prioritize its prevention. This finding appears consistent across age groups, though caution is advised for infants (<2 years) due to limited data. Lateral positioning may mitigate desaturation during deep removal. We suggest risk-stratified protocols, with lateral positioning and monitoring advised if deep removal is performed.