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Practice Problem Paper: LMA Use in the Obese Patient

Anh Bui

Case Western Reserve University FPB School of Nursing

NUND 540: Practice Focused Inquiry I

Dr. Donna Dowling

July 19th, 2021

Background and Significance

Obesity is a condition characterized by an accumulation of excessive adipose tissue and

can be defined as a body mass index (BMI) greater than 30 kg/m^2 (CDC, 2021). The incidence

of obesity, particularly in the US, is increasing at an alarming rate. In fact, 42.4% of the

American populace in 2017-2018 was considered obese (CDC, 2021). Therefore, anesthesia

providers now routinely care for the obese patient in the peri-operative area on a consistent basis.

As such, it becomes imperative that the anesthesia provider understands how obesity affects his

or her practice while taking into account the implications it plays in airway management.

The obese patient frequently has comorbid conditions such as obstructive sleep apnea,

redundant soft tissue surrounding the airway, type 2 diabetes mellitus, gastroesophageal reflux,

and gastroparesis that increases his or her risk of airway complications such as increased

incidence of difficulty in mask ventilation, difficulty in intubation, difficulty in laryngoscopy,

difficulty in placing a supraglottic airway, and a tendency for the patient to aspirate (Mason-

Nguyen et al, 2017). The pathophysiological changes of obesity include causing cells to become

increasingly resistant to insulin which often times leads to the development of type 2 diabetes.

Diabetes eventually causes damage to the nerves that control how quickly the stomach empties,

thus slowing down digestion. This delayed gastric emptying, known as gastroparesis, can lead to

protracted gastric retention of food and fluids that have an increased tendency to move

retrogradely up the esophagus, a condition known as gastroesophageal reflux disease (GERD)

(Kuznik et al, 2020). Diabetes, gastroparesis, and GERD increase the risk of aspiration

perioperatively in the patient whose ability to protect his or her airway is impaired by anesthesia

(Mason-Nguyen et al, 2017).

The aforementioned comorbid conditions have led anesthesia providers, historically, to

favor endotracheal intubation over placement of a laryngeal mask airway (LMA) as the airway

management of choice for the obese patient, because of the endotracheal tube’s presumed ability

to decrease the risk of aspiration (Godoroja et al, 2019). However, there is a lack of evidence

supporting the superiority of endotracheal intubation over supraglottic device placement in this

population. Furthermore, despite the fact that obesity affects nearly half the American populace

and LMAs are being routinely used in this population to manage airways perioperatively, there is

a dearth of evidence-based research into supraglottic airway management of the obese surgical

patient (Gill et al, 2020). Endotracheal intubation carries the risk of nerve damage,

laryngotracheal trauma, and sore throat (Gill et al, 2020). On the other hand, placement of a

supraglottic device is less stimulating, is easier to place, and less damaging to dentition when

compared to direct laryngoscopy and endotracheal intubation (Mason-Nguyen et al, 2017). As

such, it is crucial to evaluate alternative airway management to endotracheal intubation. The

purpose of this proposed project is to examine the safety and efficacy of LMA usage in the

hospital setting by evaluating the incidence of adverse airway complications and intraoperative

changes to airway management in the obese patient population compared to the healthy-weight

patient population by conducting a retrospective chart review at the tertiary care center in which

I train.

Potential Research Questions

A few potential research questions that arose as part of my research into this topic

include: 1) What are the differences in the incidence of adverse airway events between obese as

compared to healthy-weight patients who have LMA used for airway management during

surgery? 2) What factors (such as patient positioning, expertise of the anesthesia provider, etc.)
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Practice Problem Paper: LMA Use in the Obese Patient

impact the incidence of adverse airway complications with LMA use in the obese patient

population?

Literature Review

The laryngeal mask airway (LMA) was invented by Dr. Archie Brain in 1981 for

situations when an anesthesia provider needed a better method of controlling a patient’s airway

than by face mask, but endotracheal intubation was excessive. The LMA also proved to be less

hemodynamically stressful than direct laryngoscopy and endotracheal intubation (Jones, 1995).

The use of a LMA has a lower incidence of laryngospasm, coughing, post-operative hoarse

voice, sore throat, nausea, and vomiting when compared to the use of an endotracheal tube (ETT)

(Yu et al., 2010). Moreover, the use of a LMA necessitates less anesthetic, negates the need for

neuromuscular blockade, improves respiratory stability, and causes less restriction of

mucociliary clearance (Timmerman et al., 2015). However, there are limitations to the use of a

supraglottic airway like the LMA—mainly the risk of aspiration and inadequate positive airway

pressure needed for sufficient ventilation (Timmerman et al., 2015). The limitations of an LMA

can be further exacerbated when used in obese patients, due to their increased likelihood of

having delayed gastric emptying leading to increased risk of aspiration and large body habitus

restricting lung expansion for sufficient ventilation (Mason-Nguyen et al, 2017). While the

likelihood of adverse events occurring with LMA use is low, when it does it occur, the events

can be catastrophic and contribute to the morbidity and mortality of patients.

The purpose of this literature review is to identify current research evidence concerning

the laryngeal mask airway, obesity, and the implications of obesity on airway management.

Furthermore, the literature review will identify areas of prior research to identify gaps in research
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Practice Problem Paper: LMA Use in the Obese Patient

and identify the need for additional research—in particular, my own research into the safety and

efficacy of LMA usage in the obese patient in a tertiary care center.

Design/Level of Evidence

Of the 8 articles chosen for the literature review, 2 of the articles (Mason-Nguyen et al,

2017 and Nicholson et al, 2014) are systematic reviews, which are considered the strongest level

of evidence on which to guide practice decisions. 2 articles (Zoremba et al, 2009 and Carron et

al, 2012) are randomized controlled trials—providing the second highest level of evidence. The

rest of the articles chosen for literature review are retrospective chart reviews that provide a

lesser level of evidence than systematic reviews and randomized controlled trials. Conducting a

prospective randomized controlled trial examining the efficacy and safety of LMA use in the

obese patient compared to endotracheal intubation is not feasible for a DNP project in the two

years I have left. Though a retrospective study has a lesser level of evidence, it still confers

quality information and is able to be carried out as a DNP project and thus is my choice for

design study.

Population

The population under examination in all 8 of the studies is the same, namely that of the

obese patient, with some variance in BMI from obesity to morbid obesity. However, the studies

did examine LMA use under different conditions, namely, the type of surgeries. While two

articles were systematic reviews, the rest of the studies examined LMA use in different surgeries

ranging from urological, to bariatric, to appendectomies, to minor peripheral surgeries.

Results

Pourciau et al assessed the efficacy of LMA ventilation in obese patients with airway

stenosis and found that the LMA can be used without major or minor complications—for the
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Practice Problem Paper: LMA Use in the Obese Patient

patients under study did not sustain any oral or dental trauma, no significant voice changes, no

intraoperative intubation required, no patients were re-admitted within 48 hours, and it did not

cause any mortalities (2017).

Mason et al conducted a systematic review but the results were problematic as there were

methodological concerns and inconsistencies in the two evidence sources looked at for the

systematic review, the lack power to detect all complications of LMA use in the obese patient,

and small sample sizes (2017). The study found that there was limited amount and quality of

evidence to recommend LMA use in the morbidly obese, because of the potential for

catastrophic complications from use.

Many of the remaining articles of the literature review (Gill et al, 2020, Carron et al,

2012, and Zoremba et al, 2009) had similar findings. The studies found that LMA use does not

contribute to the morbidity of obese or healthy-weight patients; LMA use had less hemodynamic

and hormonal activation, less hypoxia, and less occurrences of postop nausea and vomiting

compared to endotracheal intubation in the obese population; and LMA use during minor

peripheral surgery confers advantages for moderately obese adults in terms of postop lung

function and oxygenation, respectively.

Summary and Critique

In summary, the results of my review seemed to agree that LMA use in the obese patient

is safe and conferred benefits over endotracheal intubation. Despite the fact that the LMA has

been used for the past 40 years in the perioperative setting, and the wide prevalence of obesity in

the US, there isn’t a lot of research into LMA use in the obese patient population. Furthermore,

considering that there are only two methods of airway management in general anesthesia
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Practice Problem Paper: LMA Use in the Obese Patient

(endotracheal intubation and LMA placement), it is quite surprising to see a dearth in

information on the subject matter.

Moreover, much of the research is underpowered and lacks higher levels of evidence, as

can be illustrated by the fact that a literature review of the topic only yielded two randomized

controlled trials. Considering that the possible complications and adverse events related to LMA

use can be catastrophic and contribute to the morbidity and mortality of patients, additional large,

high-quality studies must be conducted before a recommendation for LMA use in the obese

patient can be made—a recommendation backed with high levels of evidence. This gap in

literature, namely the dearth of studies into LMA use in the obese patient, will be the area in

which my proposed project will help fill. The most salient role of the anesthesia provider is to

administer safe care and ensure positive outcomes while decreasing risk and harm to patients—

and my research will help the clinician provide that based on evidence.

Methods

My study design will be a correlational retrospective chart review. The sample will

consist of adults over 18 years old, with a BMI equal to or greater than 30 kg/m^2 undergoing

breast or gynecological surgery necessitating general anesthesia and managed with an LMA at

University Hospitals from January 2021 through June 2021. Patients managed under monitored

anesthesia care, total intravenous anesthesia, endotracheally intubated, or undergoing

laparoscopic surgery will be excluded from the study. In terms of instrumentation, the data I

would gather include the incidence of adverse events such as aspiration, intraoperative change in

airway management, laryngospasm, and inadequate ventilation (drop in oxygenation saturation

by pulse oximetry or difficult ventilating). All the aforementioned data will be collected from a

retrospective chart review. Strengths of a retrospective chart review include that it is quicker
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Practice Problem Paper: LMA Use in the Obese Patient

(less time to be approved by IRB), cheaper, and easier to conduct than prospective studies, and it

is not prone to loss of follow up. A disadvantage of a retrospective studies is that the level of

evidence is inferior compared to prospective studies. Furthermore, retrospective studies are

prone to bias, subject to confounding variables, and cannot determine causation, only

association. To evaluate outcomes, I would measure the incidence of adverse events that

happened with the use of an LMA for the selected population under study. For example, to

evaluate if the obese patient is not being adequately ventilated, I would look at oxygenation

status intra-operatively, and if pulse oximetry dips below 90% without improvement upon

adjustments to PEEP and other ventilatory measures, or if intraoperative change in airway

management is needed, I would count that as an adverse event.

Summary/Conclusion

In summary, the proposed project will examine the safety and efficacy of LMA usage in

the hospital setting by evaluating the incidence of adverse airway complications and

intraoperative changes to airway management in the obese patient population compared to the

healthy-weight patient population by conducting a retrospective chart review at the tertiary care

center in which I train. The proposed project will help provide evidence for the safety of LMA

use in the obese patient population or evidence against the use of the LMA in the obese patient. I

am concerned that with a retrospective chart review, there will be selection bias and the results

will be based on convenience sampling, and are thus not representative of the general population.

Furthermore, I am worried that there will not be enough data to perform a statistical analysis, as

University Hospitals is risk adverse, and prone to intubating obese patients.

References

Centers for Disease Control and Prevention. (2021, June 7). Adult Obesity Facts. Centers for
Disease Control and Prevention. https://www.cdc.gov/obesity/data/adult.html.

Gill, J., Wood, N. L., & Joyner, M. (2020). Changes in Airway Management and Adverse Events
Related to Laryngeal Mask Airway Use in Obese Patients in the Ambulatory Surgical
Setting. American Association of Nurse Anesthetists, 88(6), 439–444.

Godoroja, D., Sorbello, M., & Margarson, M. (2019, April 16). Airway management in obese
patients: The need for lean strategies. Trends in Anaesthesia and Critical Care.
https://www.sciencedirect.com/science/article/pii/S2210844019300255.

Jones, JR (1995). Laryngeal mask airway: an alternative for the difficult airway. AANA Journal,
63(5), 444-449.

Kuźnik, E., Dudkowiak, R., Adamiec, R., & Poniewierka, E. (2020). Diabetic autonomic
neuropathy of the gastrointestinal tract. Przeglad gastroenterologiczny.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7294968/.

Mason, J.A., & Rodriguez, R. E. (2017). Laryngeal Mask Airway use in Morbidly Obese
Patients Undergoing General Anesthesia. AANA Journal, 85(2), 130-135.

Yu, S. H., & Beirne, O. R. (2010). Laryngeal mask airways have a lower risk of airway
complications compared with endotracheal intubation: a systematic review. Journal of
Oral Maxillofacial Surgery, 68(10), 2359-2376.
https://doi.org/10.1016/j.joms.2010.04.017

Pourciau, D. C., Hotard, D. P., Hayley, S., Hayley, K., Sutton, C., McWhorter, A. J., & Fink, D.
S. (2017, June 7). Safety and efficacy of laryngeal mask airway ventilation in obese
patients with airway stenosis. Wiley Online Library.

Timmermann, A., Bergner, U., Russo, S. & Guiseppe, S. (2015). Laryngeal mask airway
indications. Current Opinion in Anaesthesiology, 28(6), 717-726. 
doi: 10.1097/ACO.0000000000000262.

Zoremba M; Aust H; Eberhart L; Braunecker S; Wulf H; (2009). Comparison between intubation