European Journal of Cardiovascular Medicine

Airway management remains one of the most critical aspects of anesthetic and emergency care, with the primary goal of ensuring adequate ventilation and oxygenation during surgical and resuscitative procedures Smith I et al. (2018)[1]. Endotracheal intubation (ETI) has long been recognized as the gold standard for airway management due to its security and efficacy in protecting the airway against aspiration Walls RM et al. (2018)[2]. However, there are dangers associated with ETI, such as the need for operator expertise, the possibility of airway injuries, and sympathetic activation during laryngoscopy Wilson ME et al. (2020)[3]. The laryngeal mask airway (LMA) and other supraglottic airway devices (SGAs) have become useful substitutes in recent decades. With advantages including simplicity of insertion, less haemodynamic disruption, and a lower risk of airway problems, SGAs offer a less intrusive method of airway security Brimacombe J et al. (2021)[4]. Even while SGAs are widely used in elective operations, there are still concerns about how best to use them in patients at higher risk and what particular haemodynamic benefits they could offer over ETI Cook TM et al. (2018)[5].

Hemodynamic Response to Airway Manipulation: When an airway device is inserted, the oropharynx and larynx are mechanically stimulated, causing a strong sympathetic reaction that manifests as tachycardia and hypertension Stoelting RK et al. (2019)[6]. Catecholamine production is a sign of this sympathetic surge, which can worsen diseases such as hypertension, cerebrovascular disorders, and ischaemic heart disease Eikermann M et al. (2022)[7]. Systolic blood pressure (SBP) rises of 20–40 mmHg and average heart rate (HR) increases of 15–30 beats per minute have been seen in studies during ETI Richter JS et al. (2020)[8]. The severity of these alterations demands immediate mitigation, frequently using pharmaceutical methods such opioids or β-blockers Wang CY et al. (2021)[9].

SGAs, on the other hand, result in reduced glottic structure activation, which attenuates haemodynamic responses. Comparative research has shown that SGA insertion raises SBP by 10–20 mmHg and HR by 5–15 bpm Al-watania F et al. (2023)[10]. However, because study methodologies, measurement timing, device types, and patient groups vary, results are still few and inconsistent Keller C et al. (2022)[11].

Need for Comparative Hemodynamic Analysis

There are few quantitative evaluations in comparable patient groups, despite qualitative comparisons indicating better cardiovascular stability with SGAs. Furthermore, perioperative logistics and haemodynamic results may be further impacted by the speed and simplicity of SGA insertion Dhonneur G et al. (2021)[12]. Device selection would be guided by evidence-based review that compares insertion time, success rates, and complication profiles, especially in patients whose safety might be jeopardised by haemodynamic fluctuations. By comparing ETI with SGA insertion in adult elective surgery patients using a cross-sectional observational approach, the current study fills these gaps. The measurement of variations in mean arterial pressure (MAP), diastolic blood pressure (DBP), SBP, and HR during predetermined time periods is one of the main goals. Secondary outcomes evaluate the success of insertion, the time required to secure the airway, the perceived ease of insertion by the operator, and the frequency of problems.

Study Rationale and Hypothesis

Our hypothesis is that, in comparison to tracheal intubation, SGA insertion (more especially, LMA ProSeal®) will result in much fewer haemodynamic disturbances, take less time to secure the airway, be equally easy to insert, and have less problems.

Particularly for individuals with circulatory impairment or contraindications to an excessive sympathetic response, the findings may have implications for management. This study supports improved airway management techniques catered to patient profiles and is consistent with anaesthetic safety regulations.

Study Design and Setting

This cross-sectional observational study was conducted in the Department of Anesthesiology at Parbhani Medical College, Maharashtra, over 12 months from May 2024 to May 2025.

Sample Size

Total of 200 adult patients were enrolled, with 100 patients in Group E (Endotracheal Intubation) and 100 patients in Group S (Supraglottic Airway).

Inclusion Criteria

• Adult patients aged 18–60 years.
• ASA physical status I and II.
• Patients scheduled for elective surgical procedures under general anesthesia requiring airway management.
• Patients with normal cardiopulmonary status and no anticipated difficult airway.
• Patients providing written informed consent.

Exclusion Criteria

• Patients with known or suspected difficult airway (Mallampati class III/IV, reduced mouth opening, neck immobility, etc.).
• Patients with BMI >30 kg/m² (obesity).
• Presence of gastroesophageal reflux disease (GERD) or risk of aspiration.
• Patients with cardiovascular instability or pre-existing significant cardiovascular disease (hypertension, arrhythmias, ischemic heart disease).
• Patients with active upper respiratory tract infection or airway pathology (tumors, abscess).
• Pregnant women.
• Emergency surgical cases.

Patient Allocation

Patients were assigned into two groups based on the airway device used:

• Group E: Endotracheal Intubation (ETI)
• Group S: Supraglottic Airway (LMA ProSeal®)

Anesthesia Protocol

• All patients were pre-medicated with midazolam 0.05 mg/kg IV and fentanyl 2 μg/kg IV.
• Induction was performed using propofol 2 mg/kg IV.
• Muscle relaxation was achieved using vecuronium 0.1 mg/kg IV.
• Maintenance was done with isoflurane 1–1.5% in a mixture of 50% nitrous oxide and oxygen.

Airway Management

• Group E: Endotracheal intubation was performed using a Macintosh laryngoscope. The endotracheal tube cuff was inflated to achieve a pressure of 20–25 cm H₂O.
• Group S: LMA ProSeal® was inserted following standard technique, and the cuff was inflated appropriately to achieve a seal. Correct placement was confirmed by chest rise, auscultation, and capnography.

Parameters Measured

Hemodynamic Parameters:

Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), and Mean Arterial Pressure (MAP) were recorded at:

• Baseline (pre-induction)
• Pre-insertion (after induction, before device insertion)
• During insertion (at peak stimulation)
• Immediately post-insertion
• At 1, 3, and 5 minutes post-insertion

                     Insertion Parameters:

• Time to secure the airway (from device pick-up to confirmation of airway placement).
• Number of attempts required for successful placement.
• Ease of insertion (assessed on a Likert scale 1–5).

Complications Monitored:

• Sore throat, blood on device, laryngospasm, oxygen desaturation (SpO₂ <92%).

Statistical Analysis

• Data were analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY).
• Continuous variables were expressed as mean ± standard deviation (SD) and compared using independent t-test.
• Categorical variables were expressed as proportions (%) and compared using the Chi-square test.
• Repeated measures ANOVA was used for comparing hemodynamic parameters across time intervals.
• A p-value <0.05 was considered statistically significant.

Table 1: Baseline Characteristics

                                      No significant differences between groups.

The baseline clinical and demographic characteristics of the patients in both groups are collected in this table. There was no statistically significant difference in the mean age of the patients between Group E (36.5 ± 10.2 years) and Group S (37.1 ± 11.0 years) (p = 0.65). In both groups, the gender distribution was about similar (58 men for every 42 women in Group E compared to 60 men for every 40 women in Group S; p = 0.79). Group E and Group S had mean body mass indices (BMIs) of 23.8 ± 3.1 and 24.1 ± 3.4 kg/m², respectively (p = 0.52). The distribution of ASA physical status I and II and the average length of operation were likewise comparable between groups (p > 0.05). These results minimise potential confounding factors by confirming that both groups were well-matched for baseline data.

Table 2: Hemodynamic Parameters – Heart Rate (mean ± SD, bpm)

The heart rate (HR) patterns at different peri-insertion time points are shown in this table. There were no significant changes (p > 0.05) in the baseline and pre-insertion HR values between Group E (78 ± 10 bpm and 76 ± 9 bpm, respectively) and Group S (77 ± 9 bpm and 75 ± 9 bpm, respectively). However, Group E's HR increased by 103 ± 15 bpm during insertion, which was substantially greater than Group S's (87 ± 12 bpm, p < 0.001). Both immediately after insertion (98 ± 14 bpm vs. 83 ± 11 bpm, p < 0.001) and one minute later (92 ± 12 bpm vs. 80 ± 10 bpm, p < 0.001), this higher HR remained. At 3 minutes post-insertion, Group E continued to demonstrate a higher HR (p = 0.002), but by 5 minutes post-insertion, the difference between groups was not statistically significant (p = 0.06), indicating a return towards baseline levels.

Table 3: Hemodynamic Parameters – Blood Pressure (SBP, DBP, MAP)

The trends for mean arterial pressure (MAP), diastolic blood pressure (DBP), and systolic blood pressure (SBP) at different peri-insertion intervals are shown in this table. In both groups, baseline SBP, DBP, and MAP were similar (p > 0.05). Group E's SBP increased significantly during insertion (157 ± 18 mmHg) in contrast to Group S's (139 ± 15 mmHg, p < 0.001). DBP (98 ± 10 mmHg vs. 88 ± 9 mmHg, p < 0.001) and MAP (117 ± 11 mmHg vs. 105 ± 10 mmHg, p < 0.001) showed similar trends. All metrics showed this considerable rise both immediately after insertion and one minute later (p < 0.001). Differences in SBP (p = 0.005), DBP (p = 0.04), and MAP (p = 0.01) were still significant but less pronounced three minutes after insertion. By 5 minutes post-insertion, the differences between groups were no longer statistically significant (p > 0.05), reflecting recovery towards baseline values.

Table 4: Insertion Metrics and Complications

                             *Scale: 1 = very easy, 5 = very difficult.

The effectiveness of device implantation and the frequency of problems are contrasted between groups in this table. Group E took an average of 25 ± 5 seconds to secure the airway, which was substantially longer than Group S's (15 ± 4 seconds; p < 0.001). Although not statistically significant (p = 0.27), Group S's first-attempt success rate was somewhat greater (98%) than Group E's (95%). Between groups, the average number of tries was similar (p = 0.12). Group S (4.2 ± 0.5) outperformed Group E (3.5 ± 0.7; p < 0.001) in terms of ease of insertion, which was measured using a 5-point Likert scale (1 = extremely easy, 5 = very difficult).

Regarding complications, Group E experienced postoperative sore throat more often (12%) than Group S (4%; p = 0.04). Group E (10%) had substantially more blood staining of the device than Group S (2%; p = 0.01). In Group E, 2% of patients had laryngospasm, but in Group S, none did (p = 0.15). Between groups, desaturation (SpO₂ < 92%) was uncommon and similar (1% in Group E vs. 0% in Group S; p = 0.32). Group S performed better overall, exhibiting more usability and fewer difficulties

The haemodynamic responses and effectiveness of endotracheal intubation (ETI) and supraglottic airway (SGA, especially LMA ProSeal®) insertion in adult elective surgery patients were compared in this cross-sectional observational research conducted at a tertiary care centre in Maharashtra. Important results indicate that SGAs provide major benefits in terms of insertion speed, haemodynamic stability, and less problems. Quantifying changes in HR, SBP, DBP, and MAP throughout seven peri-insertion time points was our main goal. In the SGA group, we noticed noticeably reduced haemodynamic reactions. Group E saw a greater mean HR rise during insertion (+25 bpm) than Group S (+12 bpm) (p < 0.001). DBP increased by 20 vs. 11 mmHg, MAP by 24 vs. 13 mmHg, and SBP increased by 35 mmHg compared 18 mmHg. These results are in line with other research that showed sympathetic surges during ETI as a result of airway reflex stimulation brought on by laryngoscopy Richter JS et al. and Hughes PM et al. ^[8,13].

SGA devices have a gentler haemodynamic profile because they avoid direct laryngeal stimulation by avoiding the glottic opening Cook TM et al. (2018)^[5]. Our SGA results are consistent with previous research by Brimacombe et al., which found that after LMA installation, typical HR rises of 10 bpm and BP elevations of 15 mmHg occurred Brimacombe J et al. (2024)^[14]. It has been common practice to pharmacologically minimise haemodynamic response during ETI by using drugs such lignocaine, fentanyl, or esmolol; nevertheless, our findings indicate that device selection has a significant role and may lessen pharmacologic load.

Compared to ETI (25 ± 5 s, p < 0.001), SGAs significantly reduced the time needed to create airway (15 ± 4 s). SGAs simplify the process by doing away with the need to put a laryngoscope and inflate the tracheal tube's cuff. Other comparative experiments have reported similar efficiency Keller C et al. and Sharma D et al. ^[11,15]. In emergency situations or rapid sequence inductions, when seconds might affect oxygenation, a quicker airway construction is crucial.

SGAs had a little greater first-attempt success rate (98% vs. 95%), but the difference was not statistically significant (p = 0.27). The >95% first-pass success rates in both groups were indicative of routine elective settings and skilled anaesthesia physicians. SGAs were preferred to ETIs in terms of ease-of-insertion scores (mean 1.8 on a 5-point scale), suggesting that SGAs may lessen procedural stress, entail less technical manoeuvring, and correspond with operator subjective comfort Kovac AL et al. (2022)^[16].

ETI was linked to more cases of visible blood staining (10% vs. 2%) and sore throat (12% vs. 4%), which were probably caused by contact trauma during cuff passage and laryngoscopy. These percentages are in line with previous research evaluating airway problems following surgery Jaensson M et al. (2020)^[17]. The tendency favoured SGAs, even if laryngospasm and desaturation were uncommon and statistically similar. SGAs' safety profile encourages their continued usage in appropriate elective situations.

This cross-sectional study comparing endotracheal intubation (ETI) and supraglottic airway (SGA) insertion in 200 adult elective surgical patients indicates several key advantages for SGAs:

1. Hemodynamic Stability: At five assessed intervals around device implantation, SGAs resulted in noticeably lower increases in heart rate, systolic and diastolic blood pressure, and mean arterial pressure. In comparison to ETI, peak increases were almost cut in half (+10–15 bpm vs. +25 bpm HR rise; +18 mmHg vs. +35 mmHg SBP rise). Patients with ischaemic heart disease, hypertension, or cerebrovascular risk benefit from this decrease in cardiovascular stimulation because even brief spikes might have negative outcomes.
2. Expedient Airway Management: Due to their smoother installation without requiring direct laryngeal manipulation, SGAs took much less time to secure the airway (mean 15 ± 4 s) than ETIs (mean 25 ± 5 s). These benefits are especially important in situations where seconds can make all the difference, including in emergency situations, transport scenarios, or quick sequence induction.
3. High Success and Ease of Use: Both groups had high first-attempt insertion success rates (>95%), with SGAs marginally but not substantially exceeding ETI. SGAs were also favoured by the ease-of-insertion score, which highlighted their potential for wider use by less experienced physicians and their lower procedural complexity.
4. Reduced Complications: Intraoral haemorrhage and postoperative sore throat were considerably less common when SGA was used. SGAs showed a better patient-friendly side effect profile, which was consistent with increased postoperative comfort, even though both intubation and SGA were safe in elective settings.

LIMITATIONS OF THE STUDY

• Observational Design: Without randomization, selection bias may affect group allocations, though comparable baseline parameters mitigate this risk.
• Homogeneous Patient Population: ASA I–II, elective cases exclude high-risk or emergency scenarios.
• Single-SGA Type: Use of LMA ProSeal® limits generalization to other airway devices.
• Fixed Pharmacologic Regimen: Results may vary with different anesthesia protocols or adjunct medications.

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