Comparison of standard, direct laryngoscopy, and videolaryngoscopy for LMA insertion in children

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Created On: 10/03/2026

Safe and effective airway management in pediatric anesthesia remains a critical challenge, particularly when using second-generation supraglottic airway devices.

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Key take away

Videolaryngoscopy delivers the highest oropharyngeal leak pressure and best glottic visualization, making it the most effective technique for laryngeal mask airway ProSeal placement in children.

Background

Safe and effective airway management in pediatric anesthesia remains a critical challenge, particularly when using second-generation supraglottic airway devices. Achieving optimal ventilation and minimizing air leakage are essential for preventing perioperative respiratory complications.

This prospective randomized study evaluated 3 different laryngeal mask airway (LMA) ProSeal insertion techniques—standard digital insertion, direct laryngoscopy, and videolaryngoscopy—and compared their impact on oropharyngeal leak pressure (OLP), insertion success rate, and fiberoptic glottic visualization in children.

Method

Overall, 150 children (aged 1–10 years) undergoing short elective surgeries (≤90 minutes) were included. Volunteers were randomized to one of the three groups:

Standard digital technique (SD group)
Direct laryngoscopy-assisted insertion (DL group)
Videolaryngoscopy-guided insertion (VL group)

After LMA ProSeal placement, OLP was examined by detecting air leakage at the thyroid cartilage during the closure of the adjustable pressure-limiting valve up to 30 cmH2O. For assessing glottic alignment and positioning accuracy, a fiberoptic bronchoscope was used.

Result

Out of 159 screened patients, 150 were examined according to the protocol.

The VL group achieved the highest OLP, markedly higher than the DL group and SD group. Furthermore, the DL group demonstrated higher OLP than the standard technique.
First-attempt success rates were comparable between VL and DL groups but slightly lower in the SD group, though not statistically significant.
Insertion time was longer in the VL and DL groups as opposed to the SD group, with no pivotal difference between VL and DL (Table 1).

Fiberoptic glottic view scores were superior in the VL group as opposed to both the DL and SD groups.
Additional airway maneuvers were required more frequently in VL and DL groups when compared to SD.

Conclusion

Videolaryngoscopy achieved the highest OLP and superior fiberoptic glottic views, ensuring optimal supraglottic airway device placement, while direct laryngoscopy improved outcomes over the standard technique but remained less efficient than videolaryngoscopy.