Most important finding of our study is also concordant with results of Goudsouzian et al. [
8] and Monclus et al. [
10], where the radiologically defined malposition of the LMA did not have impact on clinical performance of the laryngeal mask too. Our results support the definition of the correct position of the LMA defined by Goudsouzian [
5] and Vialet [
11] - proximal cuff opposite to the cervical vertebrae C1 or C2. In view of our results, the position of the distal cuff cannot be taken into account, when considering the ideal position of the LMAU due to the high variability (from C3 to T2 vertebrae, Goudsouzian et al. [
5] – C4-T1). In all patients in the cohort the LMAU was successfully introduced and the overall 1st attempt success rate (91.1%) of LMAU introduction is comparable to previously published data by Lopez-Gil et al. [
3,
4] (90%) and Pournajafian et al. [
13] (80.6%), however higher success rate was reported when using Ambu AuraOnce mask (95% first attempt success) [
10]. The higher incidence and higher OR for overall malposition in smaller LMAU (size 1 and 1.5) is consistent with Monclus et al. [
10], however also higher incidence and OR in bigger LMAU (size 3 and 4) was detected in our cohort. LMAU size 3 + 4, however represents only 3.4% (
n = 7) patients from the whole cohort, so there can be high risk of bias. One of the possible explanations of the higher detected 1st attempt success rate in trainees compared to consultants can be the daily anaesthesiology routine of trainees, compared to standard daily consultant practice. The possible explanation for the higher incidence of malposition in trainees could be the lower incidence of reposition and higher satisfaction rate with the 1st attempt insertion. LMAU is considered safe supraglottic airway with minimal failure rate, easy to use with the steep learning curve [
3,
4]. Performance of the laryngeal mask remains to be almost ideal, which is underlined by the 0% failure rate in our study cohort, with no need for alternative airway management. Laryngeal mask has currently firm and predominant position in the supraglottic airway devices group; it carries many advantages when compared to the endotracheal tube - lower incidence of cough, desaturation and laryngospasm [
2], however still, after 34 years from Dr. Brain’s pilot study [
14], the ideal position is not well defined. Based on previous data [
7] we confirmed that LMAU can be in radiologically misplaced in relatively high percentage of patients (26.2%), however the clinical impact of radiological malposition remained consistently nonsignifficant.
The clinical performance of the LMAU is based on presence of audible leak during the spontaneous or mechanical ventilation and access the peak seal pressure of the system. In the study cohort the measured mean seal pressure of the system (24 cm H
20) and the minimal audible leak incidence (3.5%) is consistent with reported results [
8,
10,
11] and supports the estimated high efficacy and low failure rate of LMAU in paediatric anaesthesia, which in combination with the minimal rate of associated complications (1.5%) in the study cohort further highlight the position of the LMAU in the airway management in paediatric anaesthesia patients. Results of the study can lead to further investigation, whether the radiological malposition can have impact on the seal of the gastric contents and therefore influence the safety of anaesthesia with LMAU for airway management.