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PEDIATRIC ANESTHESIA

Work of Breathing During Spontaneous Ventilation in Anesthetized Children: A Comparative Study Among the Face Mask, Laryngeal Mask Airway and Endotracheal Tube

Ilan Keidan, MD^*, Gavin F. Fine, MB, BCh^*, Tetsuro Kagawa, MD^*, Francis X. Schneck, MD, and Etsuro K. Motoyama, MD^*,

Departments of *Anesthesiology, Urology, and Pediatrics, University of Pittsburgh School of Medicine & Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania

Address correspondence and reprint requests to Etsuro K. Motoyama, MD, Children’s Hospital of Pittsburgh, Department of Anesthesiology, 3705 Fifth Avenue, Pittsburgh, PA 15213. Address e-mail to motoyamaek{at}anes.upmc.edu

Work of breathing (WOB) increases during general anesthesia in adults, but such information has been limited in pediatric patients. We studied WOB in 24 healthy children (mean age 2 ± 1.9 yrs), during elective urogenital surgery under 1 minimum alveolar anesthetic concentration halothane-nitrous oxide anesthesia with a caudal block while breathing spontaneously. WOB was measured with an esophageal balloon, miniature flowmeter, and a computerized (Bicore) system. In each patient, WOB was computed under four conditions: a mask without oral airway (-AW), a mask with oral airway (+AW), a laryngeal mask airway (LMA), and an endotracheal tube (ETT). With each apparatus WOB was studied both with continuous positive airway pressure (CPAP) (5–6 cm H₂O) and without CPAP (or zero end-expiratory pressure [ZEEP]). Under ZEEP, WOB (g · cm/kg) among the four apparatus were (mean ± SEM): mask (-AW) (64 ± 19.2) > mask (+AW) (44 ± 17.2), LMA (42 ± 15.6) > ETT (25.4 ± 12.4) (P < 0.05). WOB with CPAP significantly (P < 0.05) decreased from WOB with ZEEP in three groups (mask [-AW], mask [+AW], and LMA), but not in the ETT group. Tidal volume (both ZEEP and CPAP) and end-tidal PCO₂ (with CPAP only) were significantly (P < 0.05) decreased only in the ETT group, whereas no significant difference was found in respiratory rate or minute volume among the four airway apparatus groups, either with or without CPAP. The reduction in WOB, when breathing through ETT was primarily attributable to decreases in tidal volume and volume work. The finding that WOB decreases with CPAP in all groups except for the ETT group suggests that the decrease is a result of improved patency of the upper airway rather than of increases in functional residual capacity and lung compliance.

Implications: We studied work of breathing (WOB) measured with four airway devices, with and without application of continuous positive airway pressure (CPAP). Laryngeal mask airway and mask with oral airway decrease WOB compared with mask alone. CPAP decreases WOB with all devices except the endotracheal tube. Increased WOB appears mostly because of soft tissue upper airway obstruction.

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999