Standard technique versus rotational technique of insertion of Baska mask®

Sheetal; Seema Jindal; Gurkaran Kaur Sidhu; Swati Jindal; Sandeep Kaur

doi:10.4103/arwy.arwy_1_23

ORIGINAL ARTICLE

Year : 2023 | Volume : 6 | Issue : 1 | Page : 17-22

Standard technique versus rotational technique of insertion of Baska mask^®

Sheetal¹, Seema Jindal¹, Gurkaran Kaur Sidhu¹, Swati Jindal², Sandeep Kaur¹
¹ Department of Anaesthesia and Intensive Care, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
² Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India

Date of Submission	30-Jan-2023
Date of Acceptance	30-Mar-2023
Date of Web Publication	20-Apr-2023

Correspondence Address:
Dr. Gurkaran Kaur Sidhu
Department of Anaesthesia and Intensive Care, Guru Gobind Singh Medical College and Hospital, Faridkot - 151 203, Punjab
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_1_23

Abstract

Background and Aims: Baska Mask^® is a new third-generation supraglottic airway device (SGAD). The placement of Baska Mask^® using the standard technique causes posterior displacement of the tongue, leading to incorrect positioning and insertion failure. The rotation technique may alleviate this obstacle during insertion by decreasing resistance between the airway and tongue. The primary objective of this study was to compare the insertion time between the standard versus rotational technique of Baska Mask^®, and the secondary outcome measures were ease of insertion, number of attempts and postoperative airway morbidity with both techniques. Methods: One hundred consenting adults of the American Society of Anaesthesiologists I-II, aged 20–65 years of either gender scheduled for a variety of surgical procedures under general anaesthesia in a tertiary care hospital (May 2019 to November 2020), were included in the study. The patients were randomly allocated to Group S and Group R using the standard and rotation techniques, respectively. All statistical analyses were done using the SPSS (Statistical Package for the Social Sciences) software. The comparison of quantitative variables between the study groups was done using the Student's t-test and Mann–Whitney test. For comparing categorical data, the Chi-square χ² test was performed. Results: The mean insertion time was significantly higher with the standard compared to the rotation technique of Baska Mask (20.90 ± 3.13 vs. 14.84 ± 1.11 s, P = 0.000). Device insertion was easy in rotation compared to the standard technique (P = 0.031). The number of attempts required for insertion was more with the standard technique than with the rotation technique (P = 0.011). Conclusion: Although the standard technique of Baska Mask^® remains the first choice, the rotational technique of Baska Mask^® has a higher success of insertion with fewer complications than the standard technique; hence, it can be accepted as an alternative.

Keywords: Airway use MeSH keywords, rotation, standard, techniques, tongue

How to cite this article:
Sheetal, Jindal S, Sidhu GK, Jindal S, Kaur S. Standard technique versus rotational technique of insertion of Baska mask^®. Airway 2023;6:17-22

How to cite this URL:
Sheetal, Jindal S, Sidhu GK, Jindal S, Kaur S. Standard technique versus rotational technique of insertion of Baska mask^®. Airway [serial online] 2023 [cited 2023 Jun 7];6:17-22. Available from: https://www.arwy.org/text.asp?2023/6/1/17/374361

Introduction

The correct use of a supraglottic airway device (SGAD) requires less expertise and training than endotracheal intubation.^[1] Baska Mask^®, a self-sealing membranous variable-pressure cuff which adjusts to the contours of the mouth and pharynx, is conventionally placed with its concave curvature facing the mandible. This insertion technique may be hindered in some cases by the posterior displacement or folding of the tongue, which can obstruct its passage to the pharynx, thus increasing the insertion time.^[2] The rotation technique using the 90° and 180° angles may alleviate this obstacle during airway insertion by decreasing resistance between the airway and tongue.^[3] The main cause of failed insertion with supraglottic airway devices is impaction at the back of the mouth. To date, there is a paucity of studies comparing the rotational technique of Baska Mask^® with the standard technique. Hence, the insertion time of Baska Mask using the standard and rotation techniques was compared.

Materials and Methods

This prospective, randomised study was conducted in a tertiary care hospital from May 2019 to November 2020 after the Institutional Ethics Committee approval (REF/2019/04/025130, CTRI/2019/05/018922). The procedure follows guidelines laid down in the Declaration of Helsinki 2013. After written informed consent, 100 American Society of Anaesthesiologists Grade I/II patients posted for surgical procedures of <2 h duration under general anaesthesia were included in the study. The patients with cervical spine pathology, gastroesophageal reflux disease, upper respiratory tract symptoms in the previous 10 days and mouth opening <2.5 cm were excluded from the study. The patients were randomised into two groups: Group R (patient ventilated using the rotation technique) and Group S (patient ventilated using the standard technique) using a computer-generated random number table (http://www.randomiser.org). The allocation was concealed in sealed opaque envelops that were opened just before shifting the patient to the operation theatre. It was impossible to blind the device operator due to technical reasons; however, the anaesthesiologist observing the patient in the postoperative care unit, those analysing the data and the participants were blinded to the group allocation. The placement of the device was done by an anaesthesiologist who had an experience of inserting a min of 50 SGADs before this study and was not involved in the collection of data in the study. The anatomical placement of the device was confirmed by auscultation and by end-tidal carbon dioxide (ETCO₂).

After the preanaesthetic checkup, the patients were kept fasting for 8 h before surgery. Routine monitoring was done by noninvasive blood pressure, electrocardiography and pulse oximetry (SpO₂). Induction of anaesthesia was achieved with injection propofol in the dose of 2–2.5 mg/kg, morphine 0.1 mg/kg and vecuronium 0.1 mg/kg intravenous to facilitate the insertion of Baska Mask. The lungs were ventilated with 50% oxygen in nitrous oxide with 1% isoflurane. The integrity and function of Baska Mask (Logikal Health Products Pty Ltd, Morisset, NSW, Australia) were checked by occluding the airway opening of the proximal connector end with one thumb and holding the mask head with the other hand placing the other thumb over the airway opening of the mask to seal. The pressure was applied for 5 s using a reservoir bag squeeze to confirm the absence of leak in the device.^[4] The device was lubricated with water-based gel before insertion. Size 4 and 5 of Baska Mask were used for patients weighing between 50 kg and 70 kg and more than 70 kg, respectively. The device was inserted using the standard technique according to the manufacturer's guidelines, and the rotational technique derived from the back-to-front insertion technique of the Guedel airway. The device is advanced into the hypopharynx until the resistance of the posterior pharyngeal wall is felt and rotated anticlockwise through 180°. A maximum of two attempts were allowed for each technique. In case of failure with one technique, the other technique was used as an alternative. Effective ventilation was defined as SpO₂ >95%, ETCO₂ <50 mmHg and tidal volume >6 ml/kg. At the end of the surgery, the SGAD was removed when the protective reflex returned to normal.

The number of attempts required for insertion was recorded, and the failed attempt was defined as the removal of the device from the mouth before insertion. A maximum of three attempts were allowed, following which an endotracheal tube was inserted for airway management. The success of insertion was assessed by the number of insertion attempts (counted when Baska Mask^® was taken in and out of a mouth). Ease of insertion was qualitatively evaluated using a 4-point scale.^[5] The insertion time (the time between picking up the prepared mask and successful placement) was assessed in all the cases. Postoperative airway morbidities such as sore throat, dysphagia and dysphonia graded as none, mild, moderate or severe were assessed at 0, 2 and 24 h postoperatively. The sore throat was defined as constant pain or discomfort in the throat independent of swallowing; dysphonia was defined as difficulty in speaking or pain on speaking; dysphagia was defined as difficulty or pain provoked by swallowing.^[6] The data were described in terms of range, mean + standard deviation and frequencies (number of cases) as appropriate.

The comparison of quantitative variables between the study groups was done using the Student's t-test and Mann–Whitney test. The Student's t-test was used to analyse the insertion time, number of attempts, mean heart rate and mean arterial blood pressure. For comparing categorical data, i.e., size of the device, ease of insertion, intraoperative manipulations, blood staining or sore throat, Chi-square χ² test was performed. To determine whether the data were normally distributed, a Kolmogorov–Smirnov test was used. P < 0.05 was considered statistically significant. All statistical calculations were done using the SPSS (Statistical Package for the Social Sciences) version 21 (IBM Corp. Armonk, N. Y, USA) statistical program for Microsoft Windows. The sample size was estimated from the results of previous studies using the insertion time, which was the primary outcome of our study.^[7],[8] Our sample size came out to be 45 participants per group; considering a dropout of 10% with α = 0.05 and power of 80%, a total of 50 participants in each group was taken up for this study.

Results

One hundred enrolled patients completed the study [Figure 1]. These patients were comparable concerning demographic profile and ETCO₂ (P > 0.05) [Table 1]. The haemodynamic variables were comparable between the two groups (P > 0.05) [Figure 2].

Figure 1: Consort flowchart

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Table 1: Comparison of demographic variables

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Figure 2: Intraoperative mean arterial pressure and heart rate

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The mean insertion time was significantly higher with the standard technique compared to the rotation technique of Baska Mask^® ([20.90 ± 3.13 vs. 14.84 ± 1.11 s] P = 0.000) [Figure 3]. A successful insertion at the first attempt was observed in 38 (76%) patients in Group S and 47 (94%) patients in Group R. The second attempt was needed in 12 (24%) patients and 3 (6%) patients in Group S and Group R, respectively. The difference between the two groups was significant (P = 0.011) [Figure 4]. In Group S, the device insertion was very easy in 27 patients, easy in 11 patients and difficult in 12 patients. In Group R, the device insertion was very easy in 34 patients, easy in 13 patients and very difficult in three patients (P = 0.031) [Table 2].

Figure 3: IT achieved with standard versus rotation technique of Baska Mask^®. The bottom and top of the box are the first and third quartiles, the band inside the box is the median value and whiskers represent the 10^th percentile and the 90^th percentile. IT: Insertion time

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Table 2: Comparison of sore throat, blood staining, intraoperative manipulations and ease of insertion between the two techniques

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Seven out of 50 patients in Group S and two out of 50 patients in Group R required intraoperative manipulations (P > 0.005). The incidence of blood staining of the device on removal was seen in 11 (22%) patients in Group S compared to 3 (6%) patients in Group R (P = 0.041) [Table 2].

Discussion

There is a paucity of studies comparing the rotational technique of Baska Mask^® with the standard technique in the literature. Baska Mask^® and ProSeal™ LMA (PLMA) look bulkier than other SGADs. The width of the cuff and airway tube of Baska Mask^® size 4 measures 5.5 cm and 3.5 cm, respectively, while that of ProSeal™ LMA size 4 measures 6 cm and 2.5 cm, respectively.^[7],[9] The cuff of Baska Mask^® can easily be decreased in size by compressing the proximal, firmer part of the mask between the thumb and fingers, making insertion easier.

The mean insertion time of Baska Mask^® was less in Group R compared to Group S (P = 0.000) [Figure 3]. This is in accordance with the study conducted by Jeon et al.on the ProSeal™ mask airway, where the insertion time was significantly lower in the rotation group compared to the control group (P = 0.03).^[10] Even Park et al.,in their study on I-Gel™ had a similar finding, the insertion time was significantly shorter in the rotation group than in the standard group (22.4 s vs 26.9 s P = 0.016).^[11] The likely explanation for less insertion time in the rotational technique might be less resistance between the airway and tongue, thus alleviating the problem of posterior tongue fall and thus impaction of the device.^[11] The insertion time is associated with the number of attempts at insertions, and accordingly, a higher first-attempt success rate may enable a shorter insertion time.^[10],[12] Multiple attempts at device insertion can lead to prolonged apnoea and mucosal injury that may result in hypoxia, laryngospasm or sore throat. An ideal SGAD, thus, should require fewer attempts at insertion.^[8],[11] In this study, the number of attempts was more in Group S compared to Group R (P = 0.011) [Figure 4]. Our results compared well with those of Kim et al. and Ghai et al., who reported a higher incidence of multiple attempts in Group S (7.1%) compared to Group R (3.6%).^[3],[12] Thus, it is obvious from these studies that successful insertion at the first attempt alleviates the need for multiple attempts.

Figure 4: Comparison of the number of attempts

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A successful single-attempt insertion is particularly necessary for emergency situations in which the oxygen reserves are insufficient.^[13] Dhulkhed et al., in their study on Proseal™ LMA, reported a successful single-attempt insertion in 98% of the cases, using the rotation technique, and in 78% of cases in which the standard technique was employed (P = 0.001).^[14] Likewise, Hwang et al., in their study on ProSeal™ LMA, reported a 100% successful single-attempt insertion in 100% of the cases, using the rotation technique, and in 85% of the cases in which the standard technique was employed (P < 0.001).^[15] The ease of insertion was evaluated as very easy, easy, difficult and very difficult. Device insertion was very easy in Group R compared to Group S [P = 0.031, [Table 2]]. The 90° rotation technique improves the ease of insertion of the LMA ProSeal™ in children, and it decreases the risk of pharyngeal trauma. The probable reason for this finding was the high number of successful first attempt at insertion in Group R.^[16]

In the present study, there was an increased incidence of blood staining of the device following the removal in Group S. Kim et al. reported a higher incidence of blood staining of the device in the standard technique due to a decreased resistance between the SGAD and the posterior pharyngeal mucosa, which results in a comparatively smooth advancement of the device, ultimately resulting in a less trauma and blood staining.^[12]

The incidence of sore throat is significantly higher among the patients in Group S compared to Group R (P < 0.05) [Table 2]. Hwang et al. reported 8% incidence of sore throat using the rotational technique versus 25% incidence using the standard technique (P = 0.005).^[15] Jeon et al. reported a greater incidence of sore throat in the standard compared to the rotational technique (33% vs 12% P = 0.009), thus favouring the latter.^[11] The likely explanation for an increased incidence of sore throat may be a higher number of attempts leading to more trauma, thus increased likelihood of sore throat.

More number of manipulations were required in Group S compared to Group R; however, the ventilation was not compromised in any patient as evidenced by maintained ETCO₂ (P > 0.05), which is in accordance with the study conducted by Kim et al. They noted a fewer number of patients requiring manipulations with the rotation technique (29% in rotational vs 39% in the standard technique; P > 0.05).^[12]

Postoperatively, none of the patients in both groups complained of dysphagia or dysphonia or any intraoperative complication. The haemodynamic variables remained within normal limits during the whole procedure in all the patients.

The limitation of our study was that the position of the airway device was not assessed with the fiberoptic laryngoscope; however, fiberoptic assessment of position is not performed in a routine clinical setting, and perfect positioning is not necessary for maintaining a satisfactory airway function. The operator could not be blinded as all device insertions were performed by a single experienced anaesthesiologist; hence, our results may not apply to untrained personnel. Furthermore, we did not consider the oral hygiene/dentition of the patients. Poor oral hygiene and poor dentition are the confounding variables that can affect the outcome. We excluded obese patients and patients undergoing laparoscopic surgeries from our studies; hence, the results may not apply to them.

Conclusion

We conclude that Baska Mask^® with the rotational technique has a faster insertion time than the standard technique. The rotation technique is associated with easy insertion, higher first-attempt success rate and less pharyngeal mucosal trauma and sore throat without increasing the haemodynamic response.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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