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Effects of laryngeal mask airway removal under different anesthesia states on pediatric airway complications: A systematic review and meta-analysis

anesthesiology-and-pain-management
evidence-based-medicine
pediatrics
respiratory-medicine
surgery-and-surgical-specialties

Abstract

Objective: This meta-analysis was designed to compare airway complication rates between deep versus 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 RCTs (n=1713) revealed no significant difference in overall airway complications (RR 0.93, 95% 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 significantly increased airway obstruction risk while reducing excessive secretions. Subgroup analyses demonstrated that inhalational anesthetic agent 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 confirms that light anesthesia (awake) LMA removal significantly reduces airway obstruction risk by 5.5-fold compared to deep removal in pediatric patients, but increases secretion-related complications (96% reduction with deep removal). Critically, the elevated obstruction risk with deep removal persists consistently across all age groups (>6 and <6 years), challenging age-based thresholds. Lateral positioning during deep removal reduces desaturation risk by 54% without negating secretion benefits. Protocol individualization, prioritizing obstruction-secretion tradeoffs over age, combined with mandatory lateral positioning/monitoring for deep removal, is recommended.

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