Comment On ‘Comparative analysis of LMA Blockbuster® clinical performance: Blind versus Miller laryngoscope-guided insertion in paediatric general anaesthesia – A double-blinded, randomised controlled trial’

Dear Editor, We read with interest the publication ‘Comparative analysis of LMA Blockbuster® clinical performance: Blind versus Miller laryngoscopeguided insertion in paediatric general anaesthesia – A double-blinded, randomised controlled trial’ by Bihani et al.[1] We applaud the authors for this study, which is highly relevant to paediatric practice, and would like to comment on specific concerns. First, the authors appear to have overlooked that though epiglottic downfolding is a common cause of laryngeal mask airway (LMA) malposition, LMA can have vertical and rotational malposition also, better assessed with a video-laryngoscope (than with a Miller laryngoscope blade; visual angle of 60°–80° and 15°, respectively) and ultrasound.[2-4] Second, while evaluating the placement of the device, though the positioning of the Miller laryngoscope blade in vallecula lifted the epiglottis leading to its better alignment with LMA, it only improved the first seal of LMA Blockbuster® (between LMA and epiglottis), but did not provide any information about the second seal between the distal cuff and the oesophagus. The authors do not comment on whether there was any leakage through the gastric channel of LMA (bubble test) or oesophagus (gastric insufflation) or if an orogastric tube could be inserted through the gastric channel without resistance. Third, the gastric channel of LMA Blockbuster® is soft and may, therefore, downfold on itself. In that scenario, it should be replaced with a supraglottic device with a reinforced tip configuration. Fourth, lower intracuff pressures (40–60 cm of H2O) in the paediatric population may be advisable to prevent postoperative pharyngolaryngeal complications.[5] The application of 2% lignocaine jelly used in the current study may delay the return of protective reflexes before device removal in this vulnerable paediatric cohort. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.