This randomized controlled trial compared the Laryngeal Mask Airway SupremeTM to the Laryngeal Mask Airway UniqueTM in 50 children undergoing elective surgery. The trial found that the LMA Supreme had a higher median airway leak pressure than the LMA Unique but took longer on average to successfully place. Both devices had high first attempt success rates. The LMA Supreme also had a lower incidence of gastric insufflation. Overall, the LMA Supreme performed comparably to the LMA Unique and is a suitable alternative for airway maintenance in children, particularly for those who require evacuation of gastric contents.

1. Original Article
A randomised trial comparing the laryngeal mask airway SupremeTM
with the laryngeal mask airway UniqueTM
in children*
N. Jagannathan,1
L. E. Sohn,1
A. Sawardekar,1
E. Chang,2
K. E. Langen1
and K. Anderson3
1 Assistant Professor, 3 Anesthesia Technician, Department of Pediatric Anesthesia, Children’s Memorial Hospital; Northwestern
University Feinberg School of Medicine, Chicago, IL, USA
2 Medical Student, University of Illinois Chicago, Chicago, IL, USA
Summary
We conducted a randomised controlled trial comparing the laryngeal mask airway Supreme
TM
with the laryngeal mask airway
UniqueTM
in children. Fifty children presenting for elective surgery were randomly assigned to receive either the laryngeal mask
airway Supreme or laryngeal mask airway Unique. The outcomes measured were airway leak pressure, ease and time for
insertion, insertion success rate, fibreoptic examination, incidence of gastric insufflation, ease of gastric tube placement through
the laryngeal mask airway Supreme, quality of airway during anaesthetic maintenance and complications. Median (IQR [range])
time to successful device placement was shorter with the laryngeal mask airway Unique, 14.5 [13.5–16.3 (10.0–23.6)] s than with
the laryngeal mask airway Supreme, 17.4 [14.8–19.8 (11.5–29.2)] s; p = 0.007. Median (IQR [range]) airway leak pressures for
the laryngeal mask airway Supreme and laryngeal mask airway Unique were 20 [16–21 (12–22)] cmH2O and 15 [14–18 (10–
24)] cmH2O, respectively (p = 0.001). The incidence of gastric insufflation was lower with the laryngeal mask airway Supreme
(zero vs six patients), p = 0.01. In conclusion, the laryngeal mask airway Supreme performed as well as the laryngeal mask
airway Unique and is a useful alternative for airway maintenance, particularly in children who require evacuation of gastric
contents during anaesthesia.
...........................................................................................................................................................................
Correspondence to: Dr N. Jagannathan
Email: simjag2000@yahoo.com
* Presented in part at the American Society of Anesthesiologists Annual Meeting, Chicago, October 2011.
Accepted: 30 September 2011
The laryngeal mask airway UniqueTM
(LMA Unique) (LMA
North America, San Diego, CA, USA) and its reusable
version, the LMA Classic
TM
, play an integral role in airway
management for children [1, 2]. The laryngeal mask airway
SupremeTM
(LMA Supreme) (LMA North America) is a
new single-use laryngeal mask airway with structural
modifications which include a curved rigid airway tubing,
a channel for passage of a gastric drain tube and a larger
cuff. The LMA Supreme was recently released in two sizes (1
and 2) for children, with an anticipated release of sizes 1.5
and 2.5 in mid-2012. There have been numerous studies
evaluating the LMA Supreme in adults, [3–8] but no clinical
studies to date analysing the performance of the LMA
Supreme in children. Therefore, the aim of this prospective
randomised study was to evaluate the clinical performance
of the LMA Supreme compared with the LMA Unique. On
the basis of design differences, we hypothesised that the
LMA Supreme would have higher airway leak pressures than
the LMA Unique when standardised to the same intracuff
pressure. Ease and time to insertion, insertion success rate,
incidence of gastric insufflation, fibreoptic laryngeal view
(and drain tube view for the LMA Supreme), ease of gastric
tube placement through the LMA Supreme, quality of
airway patency during anaesthetic maintenance and com-
plications were also assessed.
Methods
This study was approved by the Children’s Memorial
Hospital Research Center’s Institutional Review Board and
written informed consent was obtained from the parents of
all patients. Children aged 6 months to 6 years, weighing
between 10 and 20 kg, of ASA physical status 1-3, who were
Anaesthesia 2012, 67, 139–144 doi:10.1111/j.1365-2044.2011.06960.x
Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland 139

2. scheduled for elective day surgery, where a size-2 LMA
Unique (10–20 kg) would normally be used for airway
maintenance, were enrolled in the study. Patients were not
studied if they had an active respiratory illness (cough, fever
and rhinorrhea) on the day of anaesthesia, or a potentially
difficult airway. Patients were screened and recruited
consecutively based on eligibility criteria and availability of
the study investigators. Fifty children (ASA 1–3) were
randomly assigned to receive either a size-2 LMA Unique or
a size-2 LMA Supreme for airway management. Surgical
details including type and duration of procedure were
recorded. The device used for each case was randomised
using a computer-generated list and placed in an opaque
envelope by an assistant not involved in the trial and only
opened by the study investigator immediately before device
insertion. The anaesthetic protocol was standardised to an
inhalational induction with 8% sevoflurane in 70% nitrous
oxide and 30% oxygen, followed by intravenous access, and
administration of fentanyl 1 lg.kg)1
. Ventilation of the
lungs was continued until the heart rate was at least 20%
lower than pre-fentanyl values, and an end-tidal sevoflurane
concentration of 3% was obtained before device insertion.
Adequate anaesthetic depth was confirmed by lack of a
motor response to jaw thrust [9]. A supplementary dose of
1 lg.kg)1
fentanyl was allowed if the depth of anaesthesia
was deemed insufficient for device placement. Each device
was fully deflated and lubricated with a water-based agent
and inserted according to the manufacturer’s recommenda-
tions. Neuromuscular blockade was not administered to any
patient. Study parameters were measured and recorded (ease
and time to successful insertion, insertion success rate,
airway leak pressure, gastric insufflation, fibreoptic view,
ease of gastric tube placement through the LMA Supreme,
and quality of airway during anaesthetic maintenance).
Three investigators (NJ, LS, AS) experienced in using
both devices (over 500 uses with the LMA Unique and 20
uses with the LMA Supreme) performed all the insertions
and were involved in every case. One investigator managed
the airway, inserted the device and obtained the fibreoptic
views for grading, and a second investigator monitored the
intracuff pressure. A third investigator, who was positioned
behind a surgical drape, recorded the airway leak pressures,
and assessed gastric insufflation. An observer (KA) assisted
with measurement of time, recorded the fibreoptic views and
ensured collection of all data.
With the patient’s head in a neutral position, the time to
successful insertion was measured from the moment the
facemask was removed until the first capnography upstroke
after insertion. The intracuff pressure was then standardised
to 60 mmHg using an aneroid cuff pressure gauge (AmbuÒ
Inc. Glen Burnie, MD, USA). The ease of placement was
assessed using a subjective scale of 1–4 (1 = no resistance,
2 = mild resistance, 3 = moderate resistance, 4 = inability to
place the device). The insertion was recorded as a failure if the
placement of the device required more than two attempts, or
if there was lack of a square-wave capnograph tracing,
evidence of airway obstruction (oxygen desaturation < 90%,
abnormal thoraco-abdominal movements, or obstructive
noises), or inadequate ventilation (an inability to generate
7 ml.kg)1
tidal volumes regardless of the mode of ventilation,
or an audible leak through the drain tube of the LMA
Supreme not correctable with gentle advancement of the
device). The trachea was intubated with an appropriately
sized tracheal tube if the device could not be placed
successfully within two attempts. To determine the leak
pressure, the expiratory valve was closed and a fresh gas flow
of 3 l.min)1
was set until equilibrium was reached [10]
(airway pressure was not allowed to exceed 40 cmH20), and
then released completely. Auscultation with a stethoscope
was performed over the epigastrium during leak pressure
testing to detect the occurrence of gastric insufflation [11]. A
flexible fibreoptic scope (Olympus America Inc, LF-P;
3.1 mm Melville, NY, USA) was then used to view and
record the anatomical alignment of the device in relation to
the larynx. The images were graded as follows [12]: grade 1,
larynx only seen; grade 2, larynx and posterior surface of
epiglottis seen; grade 3, larynx and anterior surface of
epiglottis seen, less than 50% visual obstruction of epiglottis
to larynx; grade 4, epiglottis downfolded and anterior surface
seen, greater than 50% visual obstruction of epiglottis to
larynx; grade 5, epiglottis downfolded and larynx not seen
directly. For the patients receiving the LMA Supreme, the
flexible fibreoptic scope was then placed through the drain
tube to determine the anatomical alignment of the device
relative to the upper oesophageal sphincter. The images were
graded as follows [13]: grade 1, open upper oesophageal
sphincter (a clear view down the oesophagus); grade 2, open
hypopharynx (short conical tube of mucosa visible from
drainage tube); grade 3, closed hypopharynx (mucosa
blocking the end of the drainage tube); grade 4, other (glottis,
epiglottis, arytenoids). Subsequently, a 10-FG gastric tube
(Salem Sump
TM
; Tyco Healthcare, Crystal Lake, IL, USA) was
placed through the drain tube port, and the ease of gastric
tube placement was assessed based on a subjective scale:
(1 = easy, 2 = difficult 3 = unable to pass). Insertion of the
gastric tube into the stomach was confirmed by aspiration of
gastric contents and ⁄ or insufflation of air heard on auscul-
tation over the epigastrium. The mode of ventilation for
maintenance of anaesthesia (spontaneous, pressure support,
or mechanical) was left to the discretion of the anaesthetist.
After the parameters were measured, the quality of airway
patency (clear, intermittent partial obstruction, intermittent
Anaesthesia 2012, 67, 139–144 Jagannathan et al. | LMA Supreme vs LMA Unique in children
140 Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland

3. complete obstruction, or complete obstruction) [4], and the
number and type of airway manipulations (gentle advance-
ment, withdrawal of device without removal, jaw thrust, or
head extension) required to maintain airway patency during
the case were also recorded. Failure of the device during the
maintenance of anaesthesia was defined as inadequate
ventilation (same criteria as above for placement failure),
airway obstruction that could not be corrected with the
airway manipulation(s) listed above or replacement with a
tracheal tube. All devices were removed under anaesthesia at
the conclusion of the procedure. Complications with each
device, such as coughing, laryngospasm, bronchospasm,
desaturation (SPO2 < 90%), gastric insufflation and blood-
staining on the device after removal, were recorded. All
patients were visited in the recovery area by a blinded
investigator, and a telephone call was made to the family the
following day by a registered nurse who was not part of the
study to document any postoperative complications such as
dysphonia, dysphagia, cough, or stridor.
Based on data published from our department [14] the
mean (SD) leak pressure for the LMA Unique size 2 was
found to be 16.1 (4.9) cmH20 in this patient population.
Using this effect size, an alpha of 0.05, and a desired power
of 0.9, we estimated that 22 patients per device would be
required to detect a projected difference of 30% for the leak
pressure (the minimum difference that is considered clin-
ically significant) between these two devices. This study was
designed to enrol 50 patients (25 in each group) allowing for
possible exclusions.
Data were recorded intra-operatively using a standar-
dised data collection sheet, and analysed using Microsoft
Excel Spreadsheet and the statistical software PASW Statis-
tics 18 (SPSS Inc., Chicago, IL, USA). Statistical comparisons
between the devices were made using paired Student’s t-tests
and Student’s t-tests for continuous data, chi-squared tests
for categorical data, and Mann–Whitney U for ordinal data.
A value of p < 0.05 was considered statistically significant.
Results
Sixty-two patients were screened for enrolment in this study.
After the study was explained and the consent read, twelve
parents declined consent to participate. There was no
violation in protocol or refusal to participate after the
consent was signed. Patients’ characteristics and surgical
data are presented in Table 1, comparative data between the
LMA Supreme and the LMA Unique are seen in Table 2,
complications are listed in Table 3 and the drain tube
assessment for the LMA Supreme is presented in Table 4.
There were no statistically significant differences with
regard to first attempt success rates of insertion, ease of
insertion, fibreoptic grade of view, quality of airway achieved,
number of airway manipulations and complications between
the LMA Supreme and LMA Unique. All devices in both
groups were successfully placed within two attempts. Only
one patient in this study required a second attempt for correct
placement. This patient was in the LMA Supreme group and
had an audible leak through the drain tube immediately after
insertion, that could not be corrected without removal of the
device. Two patients in the LMA Supreme group required
three airway manipulations, and one patient in the LMA
Unique group required one airway manipulation. There were
no instances of device failure during maintenance of anaes-
thesia, or conversion to a tracheal tube.
There were statistically significant differences for time to
successful placement of the devices, airway leak pressures and
the incidence of gastric insufflations between the LMA
Supreme and the LMA Unique (Table 2). Passage of a gastric
drain tube was successful in all children receiving the LMA
Supreme. Bloodstaining was only seen in one patient after a
second attempt insertion of an LMA Supreme, which had
been moderately difficult to place. Laryngospasm with oxygen
desaturation occurred in one patient, and was related to the
placement of an oral airway on emergence of anaesthesia,
several minutes after removal of the LMA Unique, and was
promptly resolved with continuous positive airway pressure
via bag-valve-mask ventilation. Follow-up phone calls
revealed two patients with dysphonia, one from each group,
which included the child who had mucosal trauma seen on
removal of the LMA Supreme. There were no episodes of
gastric regurgitation, aspiration, bronchospasm, or stridor in
any of the patients.
Table 1. Characteristics of patients anaesthetised using the
laryngeal mask airway (LMA) Supreme or Unique, and
operative details. Values are median (IQR [range]) or
number (proportion).
LMA Supreme
(n = 25)
LMA Unique
(n = 25)
Age; years 3.1 [2.1–4.5
(1.5–6.0)]
3.1 [1.8–4.4
(0.6–5.9)]
Sex
Male 21 (84%) 18 (72%)
Female 4 (16%) 7 (28%)
Weight; kg 15.4 [12.7–17.2
(11.3–20.0)]
15.1 [11.7–16.9
(10.0–19.5)]
ASA physical status
1 16 (64%) 13 (52%)
2 7 (28%) 12 (48%)
3 2 (8%) 0
Duration
of procedure; min
66 [54–90
(22–303)]
63 [48–87
(25–210)]
Type of surgery
Urological 12 (48%) 11 (44%)
Radiological 5 (20%) 4 (16%)
General 5 (20%) 3 (12%)
Opthalmological 1 (4%) 0
Orthopaedic 2 (8%) 7 (28%)
Jagannathan et al. | LMA Supreme vs LMA Unique in children Anaesthesia 2012, 67, 139–144
Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland 141

4. Discussion
Our main findings were that in anaesthetised children not
receiving neuromuscular blockade, the LMA Supreme was
associated with higher airway leak pressures and less gastric
insufflation when compared with the LMA Unique. How-
ever, the time to successful placement was shorter with the
LMA Unique.
The high insertion success rate for the LMA Supreme in
this study is reassuring considering the study investigators’
limited experience with the LMA Supreme compared with
the LMA Unique. These success rates suggest that a
clinician’s experience with the LMA Unique may translate
to successful placement of the LMA Supreme. The time
Table 2. Insertion characteristics for the laryngeal mask airway (LMA) Supreme or Unique. Values are median (IQR [range]),
number, or number (proportion).
LMA Supreme (n = 25) LMA Unique (n = 25) p value
Effective airway time; s 17.4 [14.8–19.8 (11.5–29.2)] 14.5 [13.5–16.3 (10.0–23.6)] 0.007
Ease of device placement*
1 ⁄ 2 ⁄ 3 ⁄ 4 24 ⁄ 0 ⁄ 1 ⁄ 0 24 ⁄ 1 ⁄ 0 ⁄ 0 0.97
Insertion success
First attempt 24 (96%) 25 (100%) 0.31
Second attempt 1 (4%) 0
Leak pressure; cmH2O 20 [16–21 (12–22)] 15 [14–18 (10–24)] 0.001
Gastric insufflation
No 25 (100%) 19 (76%) 0.01
Yes 0 6 (24%)
Fibreoptic grading
1 ⁄ 2 ⁄ 3 ⁄ 4 ⁄ 5 8 ⁄ 9 ⁄ 5 ⁄ 0 ⁄ 3 5 ⁄ 7 ⁄ 6 ⁄ 4 ⁄ 3 0.16
Airway quality
Clear 23 (92%) 24 (96%) 0.55
Intermittent partial obstruction 2 (8%) 1 (4%)
Intermittent complete obstruction 0 0
Complete obstruction 0 0
Airway manipulations
None 22 (88%) 24 (96%) 0.32
Advancement of device 2 (8%) 1 (4%)
Withdrawal of device 1 (4) 0
Jaw thrust 0 (0) 0
Head extension 0 (0) 0
Type of ventilation
Controlled 8 (32%) 9 (36%) Not calculated
Pressure support 12 (48%) 15 (60%)
Spontaneous 5 (20%) 1 (4%)
*1, no resistance; 2, minimal resistance; 3, moderate resistance; 4, unable to place device.
1, larynx only seen; 2, larynx and epiglottis posterior surface seen; 3, larynx and epiglottis tip of anterior surface seen, less than 50% visual
obstruction of epiglottis to larynx; 4, epiglottis downfolded and its anterior surface seen, greater than 50% visual obstruction of epiglottis to
larynx; 5, epiglottis downfolded and larynx cannot be seen directly [12.]
Table 3. Insertion characteristics for the laryngeal mask
airway (LMA) Supreme or Unique. Values are number
(proportion).
LMA
Supreme
(n = 25)
LMA Unique
(n = 25) p value
Intra-operative complications
None 24 (96%) 24 (96%) 0.35
Airway-related*
0 1 (4%)
Mucosal trauma 1 (4%) 0
Postoperative complications
None 24 (96%) 24 (96%) 0.35
Dysphonia 1 (4%) 1 (4%)
Dysphagia 0 0
Stridor 0 0
Cough 0 0
Sore throat 0 0
*Includes laryngospasm, bronchospasm, stridor and coughing.
Table 4. Fibreoptic assessment of the drainage tube and
gastric tube (10 FrFG) insertion for the laryngeal mask
airway Supreme (n = 25). Values are number or number
(proportion).
Fibreoptic view through drainage tube*
1 ⁄ 2 ⁄ 3 ⁄ 4 2 ⁄ 13 ⁄ 10 ⁄ 0
Ease of gastric tube placement
1 ⁄ 2 ⁄ 3 23 ⁄ 2 ⁄ 0
Successful insertion 25 (100%)
*1, open upper oesophageal sphincter (a clear view down the
oesophagus); 2, open hypopharynx (short conical tube of mucosa
visible from drainage tube); 3, closed hypopharynx (mucosa
blocking the end of the drainage tube); 4, other (glottis, epiglottis,
arytenoids) [13].
1 = easy, 2 = difficult, 3 = unable to pass.
Anaesthesia 2012, 67, 139–144 Jagannathan et al. | LMA Supreme vs LMA Unique in children
142 Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland

5. taken to establish an effective airway was significantly less
with the LMA Unique, and may be related to greater
familiarity with the LMA Unique. This difference, however,
is unlikely to be clinically significant, as none of the patients
demonstrated oxygen desaturation, and first attempt success
rates, together with ease of insertion, were similar with both
devices. The overall insertion success rates in this study are
comparable to other studies of the LMA Unique and LMA
Classic in children [15–17], and the LMA Supreme in adults
[4, 5, 7]
The higher airway leak pressures of the LMA Supreme in
this study were similar to those reported in a randomised trial
for the size-2 LMA Pro-sealÒ
[18], but lower than in other
studies [16, 19]. The leak pressures reported in this study for
the LMA Unique were within the range reported in the
literature for the size-2 LMA Classic [16, 18, 20] and LMA
Unique [14, 17]. A possible explanation for the improved
airway seal with the LMA Supreme may be due to its larger
proximal cuff when compared with the LMA Unique.
However, our LMA Supreme airway leak pressures were lower
thanthoseoftheLMASupremeinadults[3,5,7].Despitethese
leak pressure differences, the clinical impact during sponta-
neous ventilation is probably insignificant, but may be of more
concern if positive pressure ventilation were undertaken.
The incidence of gastric insufflation with the LMA
Supreme was lower than with the LMA Unique, and
comparable with previous studies of LMA Pro-Seal studies
in children [15, 18, 21]. The rate of gastric insufflation in the
LMA Unique group in the present study is similar to those
reported in LMA Classic studies [18, 20, 22]. This suggests
that the LMA Supreme may have a better hypopharyngeal
seal than the LMA Unique.
In adults, the rate of successful gastric tube placement
correlates with correct positioning of the LMA Supreme [4].
Extrapolating this finding, along with the overall adequate
ventilation and performance of the size-2 LMA Supreme in
our study, successful gastric tube insertion may also indicate
proper placement of the LMA Supreme in children. In our
study, glottic structures were not seen through the drain
tube in any of the patients, suggesting correct positioning of
the LMA Supreme. Regardless of the fibreoptic drain tube
view (even without a clear view of the upper oesophageal
sphincter), the gastric tube was successfully placed in all
patients, and is comparable with the rates seen with the
LMA Pro-Seal in children [15, 21].
Studies fully assessing the efficacy of the LMA Supreme
with regard to positive pressure ventilation still need to be
conducted in children, but the minimal manipulations
required to maintain airway patency in this study may
indicate adequate stability of the LMA Supreme for venti-
lation in children.
Consistent with previous reports on the use of the
paediatric size-2 LMA Classic, some degree of epiglottic
downfolding was seen on fibreoptic examination through
both the LMA Supreme and LMA Unique, but this may not
always correspond to functional positioning of the device [1,
23]. Even with partial or complete epiglottic downfolding,
both devices provided adequate ventilation parameters
without evidence of airway obstruction [12, 24]. Conclusive
comparisons regarding fibreoptic views are difficult, as
various randomised trials have used different scoring
systems for grading fibreoptic views.
There were no differences in the overall complication
rates between the two devices in this study, despite the LMA
Supreme’s being a larger device. Bloodstaining observed on
removal of the device may be an indication of mucosal
trauma. The mucosal trauma rate for the LMA Supreme,
based on bloodstaining, was higher in this study than with
the LMA Unique, but still low, and consistent with that
reported for the LMA Classic [20]. A possible reason for the
low mucosal trauma rate may be that most devices were
successfully placed on the first attempt without difficulty.
The bloodstaining observed in the patient in the LMA
Supreme group may have been related to a second insertion
attempt with moderate difficulty in placement. Although the
overall complication rates were similar to those from other
randomised trials involving both the LMA Classic and LMA
Pro-Seal [24], a larger number of patients are required to
assess fully the complications that may arise from use of the
LMA Supreme.
Several limitations exist in this study. First, only
children with normal airways were studied. Secondly, our
data may not be applicable for children who receive
neuromuscular blockade for positive pressure ventilation.
Thirdly, although the LMA Supreme was an effective device
for airway maintenance in this study, a greater number of
patients are required to provide more definitive conclusions
regarding the LMA Supreme’s safety profile in children.
Finally, this study was a preliminary comparative evaluation
on the use of the LMA Supreme in children, as only limited
sizes are currently available. Future prospective comparison
trials are needed when all airway sizes are released
commercially to judge the overall clinical performance of
this device in the paediatric population.
We conclude that the LMA Supreme may be a useful
alternative to the LMA Unique in children, with its
higher airway leak pressures, lower incidence of gastric
insufflation, and easy gastric access. The overall clinical
performance of both devices was similar, but clinicians
may find the LMA Supreme advantageous when the
evacuation of gastric contents is required during anaes-
thesia.
Jagannathan et al. | LMA Supreme vs LMA Unique in children Anaesthesia 2012, 67, 139–144
Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland 143

6. Acknowledgements
The authors thank the following: the anaesthesia attending
staff at Children’s Memorial Hospital for making assign-
ments and switches to allow us to recruit patients; Ellen
Stein (Children’s Memorial Hospital) for IRB assistance;
Grace Lee (Johns Hopkins Bloomberg School of Public
Health) for statistical assistance; and Patrick Tobin (Chil-
dren’s Memorial Hospital) for equipment assistance with
this study.
Competing Interests
No external funding or competing interests declared.
References
1. Cox RG, Lardner DR. Supraglottic airways in children: past lessons,
future directions. Canadian Journal of Anesthesia 2009; 56: 636–42.
2. Lopez-Gil M, Brimacombe J, Alvarez M. Safety and efficacy of the
laryngeal mask airway. A prospective survey of 1400 children.
Anaesthesia 1996; 51: 969–72.
3. Abdi W, Amathieu R, Adhoum A, et al. Sparing the larynx during
gynecological laparoscopy: a randomized trial comparing the LMA
Supreme and the ETT. Acta Anaesthesiologica Scandinavica 2010;
54: 141–6.
4. Cook TM, Gatward JJ, Handel J, et al. Evaluation of the LMA Supreme
in 100 non-paralysed patients. Anaesthesia 2009; 64: 555–62.
5. Eschertzhuber S, Brimacombe J, Hohlrieder M, Keller C. The laryngeal
mask airway Supreme–a single use laryngeal mask airway with an
oesophageal vent. A randomised, crossover study with the laryngeal
mask airway ProSeal in paralysed, anaesthetised patients. Anaes-
thesia 2009; 64: 79–83.
6. Hosten T, Gurkan Y, Ozdamar D, Tekin M, Toker K, Solak M. A new
supraglottic airway device: LMA Supreme, comparison with LMA
Proseal. Acta Anaesthesiologica Scandinavica 2009; 53: 852–7.
7. Verghese C, Ramaswamy B. LMA Supreme–a new single-use LMA
with gastric access: a report on its clinical efficacy. British Journal of
Anaesthesia 2008; 101: 405–10.
8. Teoh WH, Lee KM, Suhitharan T, Yahaya Z, Teo MM, Sia AT.
Comparison of the LMA Supreme vs the i-gel in paralysed patients
undergoing gynaecological laparoscopic surgery with controlled
ventilation. Anaesthesia 2010; 65: 1173–9.
9. Drage MP, Nunez J, Vaughan RS, Asai T. Jaw thrusting as a clinical test
to assess the adequate depth of anaesthesia for insertion of the
laryngeal mask. Anaesthesia 1996; 51: 1167–70.
10. Lopez-Gil M, Brimacombe J, Keller C. A comparison of four methods
for assessing oropharyngeal leak pressure with the laryngeal mask
airway (LMA) in paediatric patients. Pediatric Anesthesia 2001; 11:
319–21.
11. Brimacombe J, Keller C, Kurian S, Myles J. Reliability of epigastric
auscultation to detect gastric insufflation. British Journal of Anaes-
thesia 2002; 88: 127–9.
12. Park C, Bahk JH, Ahn WS, Do SH, Lee KH. The laryngeal mask airway in
infants and children. Canadian Journal of Anesthesia 2001; 48: 413–
7.
13. Brimacombe J, Keller C. The ProSeal laryngeal mask airway: a
randomized, crossover study with the standard laryngeal mask
airway in paralyzed, anesthetized patients. Anesthesiology 2000;
93: 104–9.
14. Jagannathan N, Sohn LE, Mankoo R, Langen KE, Mandler T. A
randomized crossover comparison between the Laryngeal Mask
Airway-Unique and the air-Q Intubating Laryngeal Airway in children.
Pediatric Anesthesia 2011 Sept 15; doi:10.1111/j.1460-
9592.2011.03703.x.
15. Lopez-Gil M, Brimacombe J, Garcia G. A randomized non-crossover
study comparing the ProSeal and Classic laryngeal mask airway in
anaesthetized children. British Journal of Anaesthesia 2005; 95: 827–
30.
16. Lardner DR, Cox RG, Ewen A, Dickinson D. Comparison of laryngeal
mask airway (LMA)- Proseal and the LMA Classic in ventilated
children receiving neuromuscular blockade. Canadian Journal of
Anesthesia 2008; 55: 29–35.
17. Szmuk P, Ghelber O, Matuszczak M, Rabb MF, Ezri T, Sessler DI. A
prospective, randomized comparison of cobra perilaryngeal airway
and laryngeal mask airway unique in pediatric patients. Anesthesia
and Analgesia 2008; 107: 1523–30.
18. Shimbori H, Ono K, Miwa T, Morimura N, Noguchi M, Hiroki K.
Comparison of the LMA ProSeal and LMA Classic in children. British
Journal of Anaesthesia 2004; 93: 528–31.
19. Kelly F, Sale S, Bayley G, Cook T, Stoddart P, White M. A cohort
evaluation of the pediatric ProSeal laryngeal mask airway in 100
children. Pediatric Anesthesia 2008; 18: 947–51.
20. Goldmann K, Jakob C. Size 2 ProSeal laryngeal mask airway: a
randomized, crossover investigation with the standard laryngeal
mask airway in paediatric patients. British Journal of Anaesthesia
2005; 94: 385–9.
21. Lopez-Gil M, Brimacombe J. The ProSeal laryngeal mask airway in
children. Pediatric Anesthesia 2005; 15: 229–34.
22. Goldmann K, Roettger C, Wulf H. The size 1(1 ⁄ 2) ProSeal laryngeal
mask airway in infants: a randomized, crossover investigation with
the Classic laryngeal mask airway. Anesthesia and Analgesia 2006;
102: 405–10.
23. Goudsouzian NG, Denman W, Cleveland R, Shorten G. Radiologic
localization of the laryngeal mask airway in children. Anesthesiology
1992; 77: 1085–9.
24. White MC, Cook TM, Stoddart PA. A critique of elective pediatric
supraglottic airway devices. Pediatric Anesthesia 2009; 19 (Suppl 1):
55–65.
Anaesthesia 2012, 67, 139–144 Jagannathan et al. | LMA Supreme vs LMA Unique in children
144 Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland