A prospective randomized comparison of airway seal using the novel vision-guided insertion of LMA-Supreme® and LMA-Protector®


The laryngeal mask airways supreme (LMA-Supreme™) and protector (LMA-Protector™) are generally placed blindly, often resulting in a less than optimal position and vision-guided placement has been recommended. This prospective, randomized controlled study compared the efficacy of airway seal by measuring the oropharyngeal leak pressure in 100 surgical patients who underwent a variety of non-thoracic surgery under general anaesthesia, suitable with a supraglottic airway device. Patients were allocated to either the LMA-Supreme (n = 50) or LMA-Protector (n = 50) group. All insertions were performed under vision of a videolaryngoscope using an ‘insert-detect-correct-as-you-go’ technique with standardized corrective measures. Our primary endpoint, mean oropharyngeal leak pressure, was significantly higher in the LMA-Protector (31.7 ± 2.9 cm H2O) compared to the LMA-Supreme (27.7 ± 3.5 cm H2O) group (mean difference 4.0 cm H2O, 95% confidence interval (CI) 2.7–5.3 cm H2O, p < 0.001) after achieving a near-optimal fibreoptic position in the LMA-Protector (94%) and LMA-Supreme (96%) groups. No statistically significant differences were shown for secondary outcomes of alignment, number of insertion attempts and malpositions, and final anatomical position as scored by fibreoptic evaluation. Corrective manoeuvres were required in virtually all patients to obtain a correct anatomically positioned LMA. Position outcomes of the two devices were similar except for the proportion of procedures with folds in the proximal cuff (90% LMA-Supreme vs. 2% LMA-Protector, p < 0.001), the need for intracuff pressure adjustments (80% LMA-Supreme vs. 48% LMA-Protector, p = 0.001) and size correction (18% LMA-Supreme vs. 4% LMA-Protector, p = 0.025). In conclusion, a higher oropharyngeal leak pressure can be achieved with LMA-Protector compared to LMA-Supreme with optimal anatomical position when insertion is vision-guided.

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  1. 1.

    Cook T, Woodall N, Frerk C. 4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society. Major complications of airway management in the United Kingdom. Report and findings. March 2011. ISBN 978-1-9000936-03-3. London: Royal College of Anaesthetists. https://www.rcoa.ac.uk/system/files/CSQ-NAP4-Full.pdf. Accessed 14 Feb 2018.

  2. 2.

    Shorten GD, Opie NJ, Graziotti P, Morris I, Khangure M. Assessment of upper airway anatomy in awake sedated and anaesthetized patients using magnetic resonance imaging. Anaesth Intensive Care. 1994;22:165–9.

    CAS  Article  Google Scholar 

  3. 3.

    Brimacombe JR. Laryngeal mask anesthesia—principles and practice, 2nd ed. Philadelphia:Saunders; 2005, pp. 97–99.

    Google Scholar 

  4. 4.

    Aoyama K, Takenaka I, Sata T, Shigematsu A. The triple airway manoeuvre for insertion of the laryngeal mask airway in paralyzed patients. Can J Anaesth. 1995;42:1010–6.

    CAS  Article  Google Scholar 

  5. 5.

    Moustafa MA, Abdelhady MM. Fiberoptic assessment of the laryngeal mask airway (LarySeal) position after one hour of positive pressure ventilation: an observational study. J Clin Anesth. 2014;26:480–4.

    Article  Google Scholar 

  6. 6.

    Joshi S, Sciacca RR, Solanki DR, Young WL, Mathru MM. A prospective evaluation of clinical tests for placement of laryngeal mask airways. Anesthesiology. 1998;89:1141–6.

    CAS  Article  Google Scholar 

  7. 7.

    Payne J. The use of the fibreoptic laryngoscope to confirm the position of the laryngeal mask. Anaesthesia. 1989;44:865.

    Article  Google Scholar 

  8. 8.

    Van Zundert AAJ, Kumar CM, van Zundert TCRV. Malpositioning of supraglottic airway devices: preventive and corrective strategies. Br J Anaesth. 2016;116:579–82. https://doi.org/10.1093/bja/aew104.

    Article  PubMed  Google Scholar 

  9. 9.

    Van Zundert AAJ, Gatt SP, Kumar CM, van Zundert TCRV. Vision-guided placement of supraglottic airway device prevents airway obstruction: a prospective study. Br J Anaesth. 2017;118:462–3. https://doi.org/10.1093/bja/aex010.

    Article  PubMed  Google Scholar 

  10. 10.

    Van Zundert AAJ, Gatt SP, Kumar CM, van Zundert TCRV, Pandit JJ. ‘Failed supraglottic airway’: an algorithm for suboptimally placed supraglottic airway devices based on videolaryngoscopy. Br J Anaesth. 2017;118:645–9. https://doi.org/10.1093/bja/aex093.

    Article  PubMed  Google Scholar 

  11. 11.

    Van Zundert AAJ, Skinner MW, van Zundert TCRV, Luney SR, Pandit JJ. Value of knowing physical characteristics of the airway before using it. Br J Anaesth. 2016;117:12–6. https://doi.org/10.1093/bja/aew106.

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Maitra S, Baidya DK, Bhattacharjee S, Khanna P. Laryngeal mask airway ProSeal provides higher oropharyngeal leak pressure than i-gel in adult patients under general anesthesia: a meta-analysis. J Clin Anesth. 2016;33:298–305. https://doi.org/10.1016/j.jclinane.2016.04.020.

    Article  PubMed  Google Scholar 

  13. 13.

    Keller C, Brimacombe JR, Keller K, Morris R. Comparison of four methods for assessing airway sealing pressure with the laryngeal mask airway in adult patients. Br J Anaesth. 1999;82:286–7.

    CAS  Article  Google Scholar 

  14. 14.

    Seet E. Safety and efficacy of laryngeal mask airway Supreme versus laryngeal mask airway ProSeal: a randomized controlled trial. Eur J Anaesthesiol. 2010;27:602–7. https://doi.org/10.1097/EJA.0b013e32833679e3.

    Article  PubMed  Google Scholar 

  15. 15.

    Van Zundert AAJ, Wyssusek KH. Only with an optimal position of the supraglottic airway in situ, valid conclusions can be drawn about oropharyngeal airway pressure. Ind J Anaesth. 2018;62:241–2. https://doi.org/10.4103/ija.IJA_135_18.

    Article  Google Scholar 

  16. 16.

    Van Zundert TC, Hagberg CA, Cattano D. Standardization of extraglottic airway devices, is it time yet? Anesth Analg. 2013;117:750–2. https://doi.org/10.1213/ANE.0b013e31829f368b.

    Article  PubMed  Google Scholar 

  17. 17.

    Levitan RM, Ochroch EA, Kush S, Shofer FS, Hollander JE. Assessment of airway visualization: validation of the percentage of glottic opening (POGO) scale. Acad Emerg Med. 1998;5:919–3. https://doi.org/10.1111/j.1553-2712.1998.tb02823.x.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Krage R, van Rijn C, van Groeningen D, Loer SA, Schwarte LA, Schober P. Cormack–Lehane classification revisited. Br J Anaesth. 2010;105:220–7. https://doi.org/10.1093/bja/aeq136.

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    Sng BL, Ithnin FB, Mathur D, Lew E, Han N-LR, Sia AT-H. A preliminary assessment of the LMA Protector™ in non-paralysed patients. BMC Anesthesiol. 2017;17:26. https://doi.org/10.1186/s12871-017-0323-5.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Tan LZ, Tan DJ, Seet E. Use of the laryngeal mask airway (LMA) Protector for shoulder surgeries in beach-chair position: a case series. J Clin Anesth. 2017;39:110–11. https://doi.org/10.1016/j.jclinane.2017.03.036.

    Article  PubMed  Google Scholar 

  21. 21.

    Tan LZ, Tan DJA, Seet E. Laryngeal mask airway protector™: Advanced uses for laparoscopic cholecystectomies. Indian J Anaesth. 2017;61:673–5. https://doi.org/10.4103/ija.IJA_240_17.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Tan LZ, Tan DJA, Seet E. Laryngeal mask airway protector™ for intubation and extubation in thyroid surgeries: a case report. Indian J Anaesth. 2018;62:545–8. https://doi.org/10.4103/ija.IJA_43_18

    Article  PubMed  PubMed Central  Google Scholar 

  23. 23.

    Kim MH, Lee JH, Choi YS, Park S, Shin S. Comparison of the laryngeal mask airway supreme and the i-gel in paralysed elderly patients. A randomised controlled trial. Eur J Anaesthesiol. 2018;35:598–604. https://doi.org/10.1097/EJA.0000000000000700.

    Article  PubMed  Google Scholar 

  24. 24.

    Chaw SH, Shariffuddin II, Foo LL, Lee PK, Pran RM, Cheang PC, Chan L. Comparison of clinical performance of size 1.5 Supreme™ LMA and Proseal™ LMA among Asian children: a randomized controlled trial. J Clin Mon Comput. 2018. https://doi.org/10.1007/s10877-018-0109-4.

    Article  Google Scholar 

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The authors thank our research nurses Heather Reynolds, Simon Holz, Molly Clarris and Lizanne Dalgleish for their expert assistance in this study.


This study was supported by departmental resources from the Royal Brisbane and Women’s Hospital, The University of Queensland, Brisbane, QLD, Australia only.

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Correspondence to André A. J. van Zundert.

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On behalf of all authors, the corresponding author states that there are no competing interests.

Ethical approval

The Royal Brisbane and Women’s Hospital Human Research Ethics Committee (HREC/15/QRBW/248, Chairperson Dr. Conor Brophy, dd 03.07.2015) approved the study. This study was registered with the Australia and New Zealand Clinical Trial Registry (ACTRN12615000783527).

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van Zundert, A.A.J., Wyssusek, K.H., Pelecanos, A. et al. A prospective randomized comparison of airway seal using the novel vision-guided insertion of LMA-Supreme® and LMA-Protector®. J Clin Monit Comput 34, 285–294 (2020). https://doi.org/10.1007/s10877-019-00301-3

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  • Airway
  • Supraglottic airway device
  • Video-laryngoscopy
  • LMA-Supreme
  • LMA-Protector
  • Oropharyngeal leak pressure