





























AEJ12

risK of comPlications using laryngeal 
masK airway versus endotracheal tube 
during general anesthesia in Pediatric 
Patients with uPPer resPiratory  
infections:  a narrative review.  
creation of the uPPer resPiratory  
infection screening tool© and 
management algorithm for children 
Presenting for general anesthesia with 
uPPer resPiratory infection©

 
Megan Grelson SRNA

Keywords 
pediatric, upper respiratory infection, anesthesia, laryngeal mask 
airway, endotracheal tube 
 

Abstract
The inflammatory process that occurs in an upper respiratory 

infection poses an increased risk of complications for children 
undergoing general anesthesia for a surgical procedure. The anes-
thesia providers need to decide which airway device, laryngeal 
mask airways or endotracheal tubes, is most appropriate and has 
less risk of adverse respiratory complications. A literature search 
was completed using EMBASE, Cumulative Index to Nursing 
and Allied Health Literature, and the Cochrane Library. Ten 
articles were found comparing the use of laryngeal mask airways 
and endotracheal tubes in children with upper respiratory infec-
tions. Synthesis of the literature concluded that laryngeal mask 
airways have a decreased risk of complications compared to 
endotracheal tubes when used in children with recent or current 
upper respiratory infections. With this information, the use of 
a laryngeal mask airway should be considered in place of an 



13Volume 2, No. 1

endotracheal tube. The Upper Respiratory Infection Screening 
Tool© and the Management Algorithm for Children Presenting 
for General Anesthesia© were designed for quick recognition of 
children at high risk for respiratory complications and provide 
management techniques for anesthesia providers to follow. 

Introduction
Upper respiratory infections (URIs) are the most common 

illnesses among children, with most children developing 6-10 
URIs a year.1 These infections can be caused by more than 
200 different viruses, the most common being the rhinovirus.1 
Children can contract any URI-causing virus through droplets in 
the air or from direct contact with someone who is ill.1 Children 
are more susceptible to the illness due to their immature immune 
systems and close contact with other children in schools and 
daycares.1 The most common symptoms of URIs are runny nose, 
cough, congestion, sore throat, and low grade fever. A complete 
list of symptoms can be found in Table 1. Upper respiratory 
infections are very common in children and may be present when 
the child is scheduled for surgery.

In 1979, McGill et al. were the first to conclude that there is 
an increased risk of respiratory complications in children with 
recent URIs who undergo general anesthesia.2 The infection 
causes an acute inflammatory process that results in hyperreac-
tivity of the airway smooth muscle that can last anywhere from 
4 to 6 weeks.3,4,5 Since this observation, anesthesia providers 
have disagreed on whether an elective surgical procedure should 
be postponed or even canceled to allow more time for the child 
to recover from a URI. However, by the time 4 to 6 weeks pass, 
a new URI may be acquired. The belief was that children with 
recent or current URIs were at an increased risk of peri- and 
postoperational complications including laryngospasm, bron-
chospasm, and/or oxygen desaturation3,4,5,6,7,8,9,10 (see Table 2). 
In 1991, Cohen and Cameron published the largest prospec-
tive observational study involving 1283 children with URIs and 



AEJ14

20876 without.11 Their research found that children presenting 
with URIs were 2 to 7 times more likely to have respiratory 
complications peri- and postoperatively.11

Upper respiratory infections increase the risk for complications 
in children, as seen in Table 2. The infection causes an acute 
inflammatory process that results in hyperreactivity of the airway 
smooth muscle that can last anywhere from 4 to 6 weeks.3,4,5 
Anesthetic gases and airway manipulation can irritate the already 
hyperreactive smooth muscle, causing an increased risk of bron-
choconstriction and laryngospasm in the child.3,4,5 An important 
part of the anesthesia provider’s tasks is to avoid stimulation of 
the larynx in the already sensitive airway, therefore decreasing 
the likeliness of laryngospasms and bronchospasms, which can 
hinder the ability to ventilate the patient.3

dIfferent InvAsIve AIrwAy devIces

Several different types of airway devices can be used during a 
general anesthetic to provide the patient the ability to spontane-
ously breathe or to provide positive pressure ventilation either 
mechanically by the ventilator or manually by the provider. The 
airway device is directly connected to the breathing circuit on the 
anesthesia machine to deliver carrier gasses to the patient.

An endotracheal tube (ETT) is “a large-bore catheter inserted 
through the mouth or nose and into the trachea to a point above 
the bifurcation of the trachea. It is used for delivering oxygen 
and other gases at or above atmospheric pressure.”12 ETTs were 
the primary means of facilitating mechanical ventilation of 
patients for decades and are still the primary means of securing 
an airway. 

Laryngeal mask airways (LMAs) were first approved by the 
U.S. Food and Drug Administration in 1991 and have since 
been used as a passive and positive-pressure ventilation device 
in surgeries.13 They are a slightly less invasive way to provide 



15Volume 2, No. 1

an airway in patients undergoing general anesthesia and have 
been gaining in popularity. Laryngeal mask airways are “inserted 
blindly into the pharynx, forming a low-pressure seal around the 
laryngeal inlet and permitting spontaneous or gentle positive-
pressure ventilation.”13

Debate has begun regarding what method of airway manage-
ment has the least laryngeal stimulation and lowest risk of 
complications to the patient.6 Current research is attempting to 
determine which airway device, an ETT or LMA, is better for 
use in children with a current or recent URI undergoing general 
anesthesia. The purpose of this study is to recognize and list the 
symptoms of a URI, describe the changes to a child’s airway due 
to a URI which result in an increased risk for respiratory compli-
cations with general anesthesia, list potential complications when 
pediatrics with URIs undergo general anesthesia, and to deter-
mine whether an ETT or LMA is best to use in children with 
current or recent URIs undergoing general anesthesia.

Methodology
A literature search was conducted using EMBASE, Cumulative 

Index to Nursing and Allied Health Literature, and the Cochrane 
Library to find articles comparing the use of ETTs and LMAs 
in pediatric patients with recent or current URIs undergoing 
general anesthesia. The keywords used were anesthes*, surgery, 
pediatric*, child*, respiratory infection, upper respiratory infec-
tion, ETT, endotracheal tube, LMA, and laryngeal mask airway. 
The “*” symbol was used as a truncation symbol to search all 
possible spellings of a root word. Keywords were combined using 
OR and AND to limit the results. The keywords were entered 
in the databases as (anesthes* OR surgery) AND (pediatric* 
OR child) AND (respiratory infection OR upper respiratory 
infection) AND (ett OR endotracheal tube OR lma OR laryn-
geal mask airway). Abstracts were reviewed from 131 articles 
with 8 relevant articles found. The reference lists from the 8 
studies were reviewed, finding an additional 2 articles meeting 



AEJ16

inclusion criteria. This search was conducted in October 2010 
and repeated in May 2011, September 2011, November 2011, 
February 2012, and March 2012, with the same articles found 
on each search. 

In order to be included in this literature review, articles had to 
compare ETTs and LMAs used in pediatric patients undergoing 
general anesthesia with a recent or current URI. The studies had 
to compare ETTs and LMAs to determine which airway device 
had the higher incidence of complications. Editorial or opinion 
pieces were included, but the clinical guidelines provided in this 
synthesis were not made based on opinion pieces.

Studies including adults in the studied population were 
excluded in this literature review. Any study that excluded 
children with recent or current URIs was excluded. If only a 
single airway device (LMA or ETT) was studied, the article was 
excluded from the literature review.

Each article was compared to the Joanna Briggs Institute 
Levels of Evidence (LOE) rating system (Table 3).14 This system 
is known worldwide and is used on all systematic reviews 
submitted to the Joanna Briggs Institute. After reading the arti-
cles, a score from 1 to 4 was given based on the characteristics of 
the article content. The LOE rating of each article can be seen in 
Table 4.

Review of Literature
Although there is a sufficient amount of research available on 

children with recent or current URIs undergoing anesthesia, there 
is not much research on what is the best airway device to use in 
those patients, an ETT or LMA. The only level 1 article in this 
literature review was the study by Tartari et al. This randomized 
control trial (RCT) consisted of 400 patients between the ages of 
6 months and 12 years.10 The subjects were assigned to either the 
LMA or ETT group, and within those groups, it was determined 



17Volume 2, No. 1

whether or not the child had a URI.10 This study determined that 
adverse respiratory events were more frequent in children with a 
URI when compared to children without a URI.10 When an ETT 
was used compared to an LMA, children with URIs had more 
adverse respiratory events including laryngospasm, stridor, and 
excessive coughing. This study advocates the use of LMAs over 
the use of ETTs in children with URIs.10

In the RCT performed by Wakhloo et al, 40 patients with clear 
rhinorrhoea and mild cough only were included in the study.4 
There was random assignment to 2 different groups, the ETT or 
LMA group, based on what airway device was used during their 
surgical procedures.4 This study found less oxygen desaturation, 
bronchospasm, and laryngeal stimulation in the LMA group as 
compared to the ETT group and an increased risk of postop-
erative complications when using an ETT.4 In the 1998 study 
performed by Tait et al, 82 patients with URIs who were eligible 
to use either a LMA or ETT in their surgery were included in 
the study and were randomly assigned to one of these airway 
devices.6 Both the studies by Wakhloo et al. and Tait et al. found 
that LMAs had more advantages and fewer respiratory related 
complications than ETTs.4,6 The advantages of using an LMA 
are decreased incidences of laryngospasm, sore throat, and bron-
chospasm.4,6 The complications seen with the ETT group were 
coughing, sore throat, laryngospasm, bronchospasms, arterial 
oxygen desaturation, and breath-holding.4,6

Tait and Malviya’s 2005 study was a literature review that 
compared 9 different studies, all of which studied the complica-
tions caused by recent or current URIs in children undergoing 
anesthesia.3 When comparing ETTs and LMAs, this study 
concluded that LMAs were associated with fewer adverse respi-
ratory events than ETTs.3 Another literature review written by 
Höhne et al. came to the conclusion that LMAs should be used 
in children with URIs undergoing anesthesia.15 Höhne et al. 
recommend, if possible, waiting 4 weeks after a URI for elective 



AEJ18

surgeries to allow healing.15 If the surgery cannot be postponed, 
LMAs should be used in those children rather than ETTs due to 
the decreased risk of complications.15

The 2001 observational survey of practice study by Parnis et 
al. showed that LMAs provide a safe and non-irritating airway 
to patients with a decreased risk of adverse reactions when 
compared to ETTs.8 The 2007 study by Homer et al. used data 
from several prospective observational and interventional studies 
to come up with their conclusion that LMAs have an increased 
amount of respiratory complications when compared to ETTs.7 

The 2008 retrospective study by Flick et al. went through 
the medical records of 130 pediatric patients who had experi-
enced a laryngospasm during anesthesia.16 This study found that 
LMAs had an increased risk of laryngospasm when compared to 
ETTs in children with URIs.16 It was not clear what caused the 
increased risk of laryngospasm with LMAs, but it was thought 
to be the accumulation of secretions in the airway during 
emergence.16

Eikermann and Cote wrote an editorial in response to a study 
by von Ungern-Sternberg where LMAs were used in children 
with and without current or recent URI symptoms.5,9 The study 
by von Ungern-Sternberg  found an increased risk of respiratory 
complications when LMAs were used in children who had URIs, 
and a lower risk of adverse respiratory complications in those 
without recent URIs.5 Eikermann and Cote argued that children 
with recent URIs were more likely to have adverse respiratory 
reactions with ETTs rather than with LMAs.9 Eikermann and 
Cote claimed that, in his experience, LMAs were a better choice 
of airway protection and had a lower risk of complications.9 In 
reply to the editorial, von Ungern-Sternberg defended his claim 
by writing that LMAs being used in children with URIs have 
an increased risk of complications.17 Both authors agreed that 
more RCTs need to be conducted to provide a clearer position 



19Volume 2, No. 1

on what airway device has the decreased risk of complications.9,17 
Both von Ungern-Sternberg and Eikermann and Cote agreed that 
children without URI symptoms in the previous 2 weeks could 
be safely anesthetized without an increased risk of respiratory 
complications.5,9

Synthesis
Eight studies have explored whether LMAs or ETTs have an 

increased risk of adverse reactions when used in children with 
recent or current URIs. An additional 2 editorials discuss the use 
of LMAs and ETTs in children with recent or current URIs.

Three articles disagree with the statement that LMAs have a 
lower rate of respiratory adverse events than ETTs in children 
with URIs.7,16,17 The 2 studies provided by Homer et al. and Flick 
et al. advocated the use of ETTs when comparing them to LMAs 
in children with recent or current URIs.7,16 The studies by Homer 
et al. and Flick et al. did not clearly define the reason for the 
increased risk of complications in LMAs, but the authors thought 
it was related to the way the airway devices were removed and 
the secretions found on the vocal cords.7,16 The study by von 
Ungern-Sternberg et al. expressed that the authors thought LMAs 
had a higher risk of complications when used in children with 
URIs.17 This original study supported the use of ETTs in children 
with current URIs but did not compare the complication rates 
between LMAs and ETTs and was not included in this review for 
that reason.5 

Of the 8 articles in which a study was performed, six articles 
have determined that LMAs have a decreased risk of complica-
tions when compared to ETTs when used in children with recent 
or current URIs.3,4,6,8,10,15 LMAs have a decreased risk of compli-
cations due to the minimal manipulation and irritation to the 
already hyperreactive airway.3,4,6,8,10,15 LMAs sit above the glottic 
opening so there is less stimulation to the laryngeal opening and 
vocal cords, limiting the risk of complications.3,4,6,8,10,15 Eikermann 



AEJ20

and Cote, in their editorial, agree from personal experience that 
LMAs have less risk of complications when compared to ETTs 
when caring for children with URIs.9

lImItAtIons of study

There were some limitations in the literature. In Tait and 
Malviya’s 2005 study, all 9 studies included in the literature 
review looked at complications caused by recent or current URIs 
in children undergoing anesthesia.3 However, not all 9 studies 
compared the different airway devices being used in the subjects. 

future studIes

An inconsistency with the literature is the amount of time 
after URI symptoms are resolved that surgery is still considered 
high risk for the child. Some of the literature suggests waiting 
2-4 weeks for surgery,3,5,9 when others suggest waiting 4-6 
weeks.4,7,8,15 A study should be performed to find the specific time 
after symptoms are resolved to consider airway manipulation 
at risk for complications or not. Most of the dispute is related 
to how long the smooth muscle of the airway is hyperreactive. 
Knowing the exact amount of time needed to completely recover 
from a URI will help anesthesia providers to plan accordingly 
for their patients. It may be extremely difficult or impossible to 
determine an exact time since all patients are different.

Intervention Overview
According to the literature, LMAs should be preferentially 

used instead of ETTs in children with recent or current URIs 
undergoing anesthesia.3,4,6,8,9,10,15 LMAs have a decreased risk of 
peri- and postoperative complications compared to ETTs in the 
hyperreactive airway.3,4,6,8,9,10,15 Endotracheal tube use in children 
with hyperreactive airways secondary to URIs results in a higher 
risk of respiratory complications including laryngospasm, bron-
chospasm, arterial oxygen desaturation, and breath-holding (a 
complete list is available in Table 2).3,4,6,8,9,10,15 



21Volume 2, No. 1

The Upper Respiratory Infection Screening Tool© (Appendix 
1) was created so parents/guardians can fill out a questionnaire 
regarding the child’s recent health prior to surgery. On the Upper 
Respiratory Infection Screening Tool©, common signs and symp-
toms are listed, and the parent/guardian is to answer whether 
the patient currently has the symptom, has had the symptom 
within the past 4 weeks, or has not had the symptom. Using this 
screening tool, anesthesia providers will be able to see quickly 
if the patient is at a higher risk for complications due to their 
current or recent URI symptoms. Symptoms 1-5 on the screening 
tool: nasal congestion, sputum production, wheezing, produc-
tive cough, and fever greater than 100.4°F (38°C), are symptoms 
associated with a severe URI.3 Two or more of those symptoms 
puts the child at higher risk for respiratory complications.3,10

The information found on the Upper Respiratory Infection 
Screening Tool© can then be used in the decision tree referred 
to as the Management Algorithm for Children Presenting 
for General Anesthesia with Upper Respiratory Infection© 
(Appendix 2). The decision tree was created as a clinical guid-
ance algorithm for anesthesia providers to refer to when deciding 
the best option for the management of the child presenting 
for surgery. To use the Management Algorithm for Children 
Presenting for General Anesthesia with Upper Respiratory 
Infection©, the clinician starts at the top with the first question, 
and each answer will lead the clinician to another question. The 
result at the end of the tree is a recommendation of the safest 
way to provide anesthesia care for the child. If the end result 
recommends proceed with caution, the anesthesia provider needs 
to ensure the child is adequately hydrated through intravenous 
fluids, humidification on the patient breathing circuit, and that 
airway manipulation is only performed when the child is deeply 
anesthetized.3,6 Medications such as sevoflurane, bronchodila-
tors and anticholinergics can be used to help minimize the risk 
of respiratory complications but are not required to be routinely 
administered.3,6



AEJ22

Summary
The current literature supports the use of LMAs over ETTs 

when used in children with recent or current URIs.3,4,6,8,9,10,15 
There is a lower risk of respiratory complications when using a 
LMA in these children.3,4,6,8,9,10,15 Anesthesia providers have the 
responsibility of selecting the right plan of care for each indi-
vidual patient based on the type of procedure and the patient’s 
health history. The Upper Respiratory Infection Screening Tool©  
and the Management Algorithm for Children Presenting for 
General Anesthesia with Upper Respiratory Infection©  provide 
a quick reference for anesthesia providers to look to for guidance 
when taking care of the pediatric population. 

Author Info
Megan Grelson SRNA
megan.grelson@gmail.com 

Acknowledgements:
This review was conducted as a student at Texas Christian 
University School of Nurse Anesthesia as part of the Doctor of 
Nursing Degree requirements. 
The author appreciates advising/guidance by Mark Welliver, 
DNP, CRNA and Hylda Nugent, DNP, CRNA Faculty TCU 
School Nurse Anesthesia.



23Volume 2, No. 1

Table 1. Signs and symptoms of URIs in infants and older childrena

Infants Older Children

●» unable to sleep ●» stuffy, runny nose

●» fussiness ●» scratchy, tickly throat

●» congestion in the nose ●» watery eyes

●» sometimes vomiting and diarrhea ●» sneezing

●» fever ●» mild hacking cough

●» congestion

●» sore throat

●» achy muscles and bones

●» headaches

●» low grade fever

●» chills

●» watery discharge from nose and throat

●» mild fatigue 

a. Data derived from Children’s Hospital Boston.1

Table 2 – Possible anesthetic complications in children with URIs

●» laryngospasm4,5,6,7,9,10 ●» stridor3,7,10 ●» secretions3,4,8

●» bronchospasm3,4,5,6,7,8 ●» hypoxemia5

●» airway 
obstruction4,5,8●» breath-holding3,4,6,8 ●» vomiting8

●» coughing3,4,5,6,7,8,9,10 ●» regurgitation8 ●» atelectasis3,5,6

●» oxygen desaturation3,5,6,7,8,9 ●» hypotension8 ●» cardiac arrest8

●» sore throat6 ●» arrhythmia8 ●» death8



AEJ24

Table 3 – The Joanna Briggs Institute Levels of Evidence14

Levels 
of 

Evidence

Feasibility 
F (1-4)

Appropriateness 
A (1-4)

Meaningfulness 
M (1-4)

Effectiveness 
E (1-4)

Economic Evidence

1 Metasynthesis of research with 
unequivocal synthesized findings

Metasynthesis of research with 
unequivocal synthesized findings

Metasynthesis of 
research with  
unequivocal  
synthesized findings

Meta-analysis (with 
homogeneity) of experi-
mental studies (eg RCT 
with concealed random-
ization) OR One or 
more large experimental 
studies with narrow 
confidence intervals

Metasynthesis (with homoge-
neity) of evaluations of impor-
tant alternative interventions 
comparing all clinically rele-
vant outcomes against appro-
priate cost measurement, and 
including a clinically sensible 
sensitivity analysis

2 Metasynthesis of research with 
credible synthesized findings

Metasynthesis of research with 
credible synthesized findings

Metasynthesis of 
research with credible 
synthesized findings

One or more smaller 
RCTs with wider confi-
dence intervals OR 
Quasi-experimental 
studies (without 
randomization)

Evaluations of important alter-
native interventions comparing 
all clinically relevant outcomes 
against appropriate cost 
measurement, and including 
a clinically sensible sensitivity 
analysis

3 a. Metasynthesis of text/opinion 
with credible synthesized findings

b. One or more single research 
studies of high quality

a. Metasynthesis of text/opinion 
with credible synthesized findings

b. One or more single research 
studies of high quality

a. Metasynthesis 
of text/opinion with 
credible synthesized 
findings

b. One or more 
single research studies 
of high quality

a. Cohort studies (with 
control group)

b. Case-controlled

c. Observational 
studies (without control 
group)

Evaluations of important alter-
native interventions comparing 
a limited number of appropriate 
cost measurement, without a 
clinically sensible sensitivity 
analysis

4 Expert opinion Expert opinion Expert opinion Expert opinion, or 
physiology bench 
research, or consensus

Expert opinion, or based on 
economic theory



25Volume 2, No. 1

Table 3 – The Joanna Briggs Institute Levels of Evidence14

Levels 
of 

Evidence

Feasibility 
F (1-4)

Appropriateness 
A (1-4)

Meaningfulness 
M (1-4)

Effectiveness 
E (1-4)

Economic Evidence

1 Metasynthesis of research with 
unequivocal synthesized findings

Metasynthesis of research with 
unequivocal synthesized findings

Metasynthesis of 
research with  
unequivocal  
synthesized findings

Meta-analysis (with 
homogeneity) of experi-
mental studies (eg RCT 
with concealed random-
ization) OR One or 
more large experimental 
studies with narrow 
confidence intervals

Metasynthesis (with homoge-
neity) of evaluations of impor-
tant alternative interventions 
comparing all clinically rele-
vant outcomes against appro-
priate cost measurement, and 
including a clinically sensible 
sensitivity analysis

2 Metasynthesis of research with 
credible synthesized findings

Metasynthesis of research with 
credible synthesized findings

Metasynthesis of 
research with credible 
synthesized findings

One or more smaller 
RCTs with wider confi-
dence intervals OR 
Quasi-experimental 
studies (without 
randomization)

Evaluations of important alter-
native interventions comparing 
all clinically relevant outcomes 
against appropriate cost 
measurement, and including 
a clinically sensible sensitivity 
analysis

3 a. Metasynthesis of text/opinion 
with credible synthesized findings

b. One or more single research 
studies of high quality

a. Metasynthesis of text/opinion 
with credible synthesized findings

b. One or more single research 
studies of high quality

a. Metasynthesis 
of text/opinion with 
credible synthesized 
findings

b. One or more 
single research studies 
of high quality

a. Cohort studies (with 
control group)

b. Case-controlled

c. Observational 
studies (without control 
group)

Evaluations of important alter-
native interventions comparing 
a limited number of appropriate 
cost measurement, without a 
clinically sensible sensitivity 
analysis

4 Expert opinion Expert opinion Expert opinion Expert opinion, or 
physiology bench 
research, or consensus

Expert opinion, or based on 
economic theory



AEJ26

Table 4 – Levels of Evidence and Study Findings

Article LOE n Study Findings

Tartari,10 
2000

1 400
RCT of LMA vs. 

ETT

LMAs had less adverse respi-
ratory events than ETTs in 
children with URIs. LMAs are 
preferred over ETTs in children 
with URIs.

Tait,6

1998
2 82

RCT of LMA vs. 
ETT 

Less coughing and oxygen desat-
uration in LMA, no broncho-
spasm in LMA. Total respira-
tory complications significantly 
greater in ETT than LMA. 
LMAs lack laryngeal stimula-
tion. “LMA seems to offer 
several advantages over the ETT 
for airway management.”

Wakhloo,4 
2007

2 40
RCT of LMA vs. 

ETT

Less oxygen desaturation, no 
bronchospasm in LMA group 
compared to ETT. ETT use 
increases risk of postopera-
tive complications. LMAs have 
decreased amount of laryn-
geal stimulation and decreased 
airway complications with URIs.

Tait,3

2005
2 - Literature Review 

More severe URI symptoms 
should wait 4 weeks for surgery. 
ETT should be avoided because 
of increased risk of respiratory 
complications. LMAs are a safe 
alternative for ETTs with signifi-
cantly less complications.



27Volume 2, No. 1

Article LOE n Study Findings

Höhne,15

2006
2 - Literature Review

LMA safe airway device, espe-
cially in children with URIs. 
Surgery should be delayed 4 
weeks if possible, when not 
possible use LMA.

Homer,7 
2007

3 335

Logistic  
regression model. 
Several prospective 
interventional and 
observational clinical 
studies.

In general, there was a higher 
percentage of adverse events 
with LMA as opposed to ETT. 
URI 2-4 weeks prior to surgery 
had the highest rate of respira-
tory complications. 

Parnis,8 
2001

3 2514

Logistic  
regression model. 
Observational survey 
of practice

Patients with ETTs had highest 
rate of adverse reactions. LMAs 
or FMs had the lowest. LMA 
provides clear, safe airway 
without irritating patient 
airway.

Flick,16 
2008

3 130

Retrospective study 
of pediatric patients 
having experienced a 
laryngospasm during 
anesthesia

Chart reviews identified that 
LMAs have an increased risk of 
laryngospasm when compared 
to ETTs. 

Eikermann,9 
2008

4 -
Editorial responding 
to von Ungern-
Sternberg’s article

Clinical observation stating 
children without URI within the 
past few weeks may be safely 
anesthetized. Disagree with von 
Ungern-Sternberg’s study that 
LMAs increase the risk of respi-
ratory complications. 

von Ungern-
Sternberg,17 

2008
4 -

In Reply to 
Eikermann and 
Cote’s editorial

“Recent URI is a risk factor for 
the occurrence of perioperative 
respiratory complications with 
the use of an LMA.”



AEJ28

Appendix 1

Upper Respiratory Infection Screening Tool©
Please check any symptoms currently present or present in the last 4 weeks.
Please answer as accurately as possible.

1. Runny Nose/Nasal Congestion 5. Fever (greater than 100.4°F)

 � Yes, Currently  � Yes, Currently

 � Yes, in last 4 weeks  � Yes, in last 4 weeks

 � No  � No

2. Sputum Production 6. Malaise (feeling unwell)

 � Yes, Currently  � Yes, Currently

 � Yes, in last 4 weeks  � Yes, in last 4 weeks

 � No  � No

3. Wheezing/Reactive Airway 7. Muscular Pains

 � Yes, Currently  � Yes, Currently

 � Yes, in last 4 weeks  � Yes, in last 4 weeks

 � No  � No

4. Productive Cough 8. Sneezing

 � Yes, Currently  � Yes, Currently

 � Yes, in last 4 weeks  � Yes, in last 4 weeks

 � No  � No



29Volume 2, No. 1

9. Hoarse Voice 10. Sore/Scratchy Throat

 � Yes, Currently  � Yes, Currently

 � Yes, in last 4 weeks  � Yes, in last 4 weeks

 � No  � No

Comments:             

              

              

              

Information provided by:           

Relationship:             

Signature:           Date:    



AEJ30

Appendix 2

management algorithm for children Presenting for general 
anesthesia with upper respiratory infection©

*When proceeding with caution, the following can help to 
reduce the risk of respiratory complications postoperatively: 
adequate IV hydration, humidification, bronchodilators, use of 
sevoflurane, anticholinergics, and ensuring adequate depth of 
anesthesia prior to airway manipulation.3,6 



31Volume 2, No. 1

references

1 Children’s Hospital Boston. Upper respiratory infection 
(common cold). Children’s Hospital Boston website. http://
www.childrenshospital.org/az/Site1719/mainpageS1719P0.
html. Accessed February 25, 2012.

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