Comparison of Cost Analyses of Laryngeal Mask Airway and Endotracheal Tube Use in Anaesthesia Management: A Prospective Study

Introduction

The primary duty of every anesthesiologist is to secure the respiratory tract and maintain control of breathing. Endotracheal tube intubation (ETT) is a well-established, traditional method that provides a highly secure airway; however, it typically requires the administration of muscle relaxants and subsequent reversal agents. Although endotracheal tube intubation (ETT) has been around for a long time, problems associated with the procedure persist1. The laryngeal mask airway (LMA), invented in the 1980s, is a supraglottic airway device used to maintain an open airway during short-term surgical procedures2. In 2001, Dr. Archibald Brain transformed the classic laryngeal mask airway (cLMA) and designed the LMA ProSeal™3. The LMA ProSeal™ has a large, wedge-shaped cuff, a drainage tube, and a bite block. Notably, the cuff provides excellent ventilation by preventing air leakage at high pressures. Additionally, the drainage tube helps prevent stomach aspiration, facilitating the insertion of a stomach tube and emptying the stomach4. The LMA ProSeal™ generally shortens induction and/or emergence times while reducing the rate of lower respiratory tract complications. The time savings and reduced complications associated with the LMA strongly highlight its advantages in many anesthetic settings. Because both ETT and LMA ProSeal™ are widely and safely used in routine anesthesia management depending on surgical requirements, comparing their procedural dynamics and economic impacts is highly relevant.

Socioeconomic changes directly affect the healthcare system. Several interventions are required to deliver healthcare at an appropriate cost without compromising quality5. Costs are generally grouped into three categories: direct, indirect, and intangible costs6,7. According to the literature, there are various types of cost analysis, such as cost minimization, cost-benefit analysis, cost-result analysis, cost-efficiency analysis, and cost-value analysis8. Direct costs are those associated with providing medical care and can be calculated using market prices. The cost analysis in our study was based on direct costs. Medical care costs include medication, consultations, examinations, expenses, and care provided by healthcare professionals.

Notably, the correct use of resources is essential for the continuity of services provided in operating rooms, especially in university hospitals. Therefore, each university hospital must conduct a cost analysis. In our country, the number of people who applied to see a physician in 2010 was 7.3 per person. The total number of applications was 538 million. Of these, approximately 21 million were made to university hospitals. University hospitals constituted 4% of the total number of applications. However, when social security hospital expenditures are analyzed, payments made to university hospitals constitute 20% of the total. In contrast, the indebtedness rate of university hospitals in 2010 (net debt/income) was 36%. Considering that the rate was only 13% for education and research hospitals affiliated with the Ministry of Health, the high rate of university hospitals is clear. This finding reveals that university hospitals have high rates of indebtedness, an unachievable balance of income and expenditure, and weakened financial sustainability. Despite the Ministry of Health's initiatives to improve the financial status of university hospitals9, their financial problems are still increasing.

Although there are some studies on the laryngeal mask airway in the literature10,11, there are a limited number of studies focusing on direct cost analysis comparison. The majority of current research is centered on clinical efficiency and complications rather than comprehensive cost-effectiveness models. To the best of our knowledge, our study is one of the few that addresses this topic in the context of plastic surgery cases. Our study aims to compare the costs and clinical outcomes of laryngeal masks and endotracheal tubes, which are both widely used in university and Ministry of Health hospitals, depending on physician's preference.

Materials and Methods

Our study was designed as a prospective, observational study. Approval was obtained from the Kahramanmaraş Sütçü İmam University Faculty of Medicine Clinical Research Ethics Committee on July 25, 2018 (number 2018/13-27). The study was conducted from August 15, 2018, to August 15, 2019, and involved plastic surgery cases. Written informed consent was obtained from all patients. The study included patients between the ages of 18 and 65 years who were expected to undergo plastic surgery lasting between 0 and 2 hours. Patients with renal or hepatic impairment, an age over 65 years, an American Society of Anesthesiologists (ASA) score of IV or higher, or impaired consciousness were excluded from the study. The type of anesthesia was decided by the consultant faculty doctor and the specialist physician based on the surgical intervention to be performed on the patient. Patients were divided into two groups: the endotracheal tube (ET) group (n = 40) and the laryngeal mask (LMA ProSeal™, The Laryngeal Mask Company Limited, Mahé, Seychelles) (LM) group (n = 40).

Preoperatively, vascular access was obtained using an 18-gauge intravenous (IV) cannula. All patients received 0.02–0.03 mg/kg IV midazolam (VEM, İlaç A.Ş, Tekirdağ, Türkiye) 30 minutes before surgery. Once the patients were in the operating room, three-lead electrocardiography, pulse oximetry, and noninvasive blood pressure monitoring (Infinity Delta XL, Dräger, Germany) were performed. Remifentanil (Ultiva, 2 mg vial, GlaxoSmithKline, UK), at a dose of 1 μg/kg, and propofol (Propofol 1% ampule, Fresenius Kabi, Germany), at a dose of 2 mg/kg, were used for anesthesia induction. An additional propofol dose was administered for intubation in both groups and recorded. Rocuronium (0.6 mg/kg, Muscuron, Koçak Farma İlaç ve Kimya Sanayi A.Ş., Istanbul, Türkiye) was administered to patients undergoing endotracheal intubation. Additionally, atropine sulfate (0.02–0.06 mL/kg, Drogsan İlaçları San. ve Tic. A.Ş., Türkiye) and neostigmine methyl sulfate (0.05 mg/kg, Adeka Pharmaceutical Industry and Trade) were administered to facilitate awakening. In Group LM, atropine sulfate and neostigmine methyl sulfate were not used to reverse muscle relaxation. Sevoflurane (Sevorane Liquid, Abbott, USA) (minimum alveolar concentration: 1%–2%) was used to maintain anesthesia. Initial mechanical ventilation was planned with a tidal volume of 7–8 mL/kg and a respiratory rate of 10–12. Patients achieved normocapnia (30–40 mmHg). Tramadol (1 mg/kg; Abdi Ibrahim İlaç San. ve Tic. A.Ş., Istanbul, Türkiye) was administered for postoperative analgesia. All drugs used during the operation were recorded. The following were recorded for all patients: age; sex; BMI; diagnosis; Mallampati and ASA scores; intubation, extubation, and operation times; and drugs used in anesthesia induction and maintenance, as well as their doses.

Our study examined price changes from July 1, 2018, to July 1, 2019. The cost analysis was based on purchasing unit prices. Oxygen and nitrous oxide consumption was not included in the cost analysis. The cost of sterilizing the laryngeal mask was also excluded. Additionally, standard expenses in both groups were excluded, as were physician and personnel expenses because they were the same for both groups.

Purchasing Unit Prices

Remifentanil (1 ampule = 2,000 mcg): 12.47 TL (500 mcg × 4; 4 × 3.1175 TL). Remifentanil is divided into four doses. Propofol (2 mg/kg): 3.80 TL. One ampule was used for each patient. Rocuronium (1 ampule = 50 mg): 5.72 TL. One ampule was used for each patient. Tramadol (1 ampule = 100 mg): 1.13 TL. One ampule was used for each patient. Atropine (1 ampule = 0.5 mg): 0.43 TL. Neostigmine (1 ampule = 0.5 mg): 0.58 TL. Sevoflurane (1 bottle): 525 TL (1/4 price: 131.25 TL per patient). Airway (1 piece): 1.69 TL. Aspirator probe (1 piece): 1.18 TL. Laryngeal mask (1 piece): 1,070 TL. Endotracheal tube: 2.5 TL.

Statistical Analysis

The data were analyzed using SPSS version 25.0 for Windows (Statistical Package for the Social Sciences). Descriptive statistical methods (number, percentage, mean, and standard deviation) were used to evaluate the data. Suitability to normal distribution was examined using a Q–Q plot, histogram, and Kolmogorov–Smirnov or Shapiro–Wilk test. Kurtosis was checked to ensure it was within the range of ±3. Chi-square analysis was used to examine homogeneous distribution in Groups ET and LM according to demographic characteristics. An independent samples t-test was performed to determine differences in quantitative data between the two groups. A p value of <0.05 was considered statistically significant.

Results

A total of 80 patients were included in the study, with 40 in each group. No significant differences were noted between the groups regarding age or BMI values (p > 0.05) (Table 1). However, a significant difference between the groups was observed in the times of intubation, extubation, and operation. The intubation and extubation times, as well as the operation time, were longer in Group ET (p < 0.001, p = 0.029, and p < 0.001, respectively) (Table 2).

*p<0.05. ASA: American Society of Anesthesiologists.

Significant intergroup differences were observed in the doses of remifentanil, propofol, rocuronium, atropine sulfate, and neostigmine methylsulfate, as well as in the number of airways used (p = 0.020, p = 0.048, p < 0.001, p < 0.001, p < 0.001, p < 0.001, respectively). The doses of remifentanil, rocuronium, atropine sulfate, and neostigmine methylsulfate, as well as the number of airways used, were higher in Group ET than in Group LM. However, the propofol dose was higher in Group LM than in Group ET (Table 3). Additionally, significant intergroup differences were noted in relation to atropine sulfate, neostigmine methyl sulfate, airway costs, and total cost averages (p < 0.001, p < 0.001, p < 0.001, respectively). Atropine sulfate, neostigmine methyl sulfate, and airway costs were higher in Group ET than in Group LM. However, the total cost was higher in Group LM than in Group ET (p < 0.001) (Table 4).

*p<0.05.

*p<0.05.

*p<0.05. TL: Turkish Lira.

Discussion

The use of laryngeal mask airways (LMAs) versus endotracheal tubes (ETTs) in anesthesia management has been widely studied, with a focus on clinical outcomes, efficiency, and cost-effectiveness. Several studies suggest that using an LMA is associated with shorter induction and recovery times, fewer perioperative complications, and potential economic benefits compared to an ETT in various surgical settings12,13. In our study, despite having longer intubation, extubation, and operation times, as well as higher doses of remifentanil, rocuronium, atropine sulfate, and neostigmine methylsulfate, and a higher number of airways used, Group ET had a lower total cost. In our study, we used LMA on a per-patient basis to take into account sterilization costs, the risk of transmitting infections, and complications associated with reuse. The fact that the unit price of the laryngeal mask (1,070 TL) is much higher than that of the endotracheal tube (2.5 TL) may explain why the ET group is more cost-effective despite the increased medication and time costs.

Although ETT is a traditional and secure method, it requires the administration of muscle relaxants and reversal agents, which may explain the prolonged intubation and extubation times observed in our study. Furthermore, clinical data indicate that ETT increases the likelihood of throat irritation and stimulation, leading to significantly higher rates of postoperative sore throat compared to the LMA ProSeal™14. Additionally, postoperative nausea and vomiting can be up to 40% more frequent in patients undergoing ETT14. In their retrospective comparative study of 157 patients who underwent dentoalveolar surgery in 2002, Todd and colleagues reported that the LMA reduced recovery time by 13 minutes compared to the ETT and lowered costs15. Furthermore, as indicated in Table 1, a statistically significant difference was observed between the ET and LM groups in terms of surgical diagnosis (p = 0.012). Therefore, when evaluating the results, it is essential to consider that diagnoses (e.g., cranial trauma, mammoplasty) may serve as confounding factors affecting the duration of surgery. In their study of elective outpatient surgeries involving healthy adults, Macario and colleagues reported that cost-effectiveness was more favorable in surgeries lasting over 40 minutes and in cases where LMA devices could be reused after being sterilized 40 times. The fact that the study was conducted in 1995 may explain the price difference compared to current conditions, and reusing an LMA after 40 sterilizations may also carry a risk of complications16.

Due to limited budgets for healthcare services, all institutions must efficiently use their available resources while striving to provide the best possible care. For this reason, cost analysis studies are necessary to compare the scope of application, effectiveness, and alternatives of various treatments17-20. Cost analysis can inform the development of future financial plans based on historical cost data21. A study observed that using an intravenous fentanyl infusion instead of nitrous oxide in low-flow anesthesia with desflurane did not affect hemodynamics. However, using a fentanyl infusion in low-flow anesthesia increases anesthesia cost and Bispectral Index (BIS) values. Notably, using BIS doubled the anesthesia cost22. A comparative study of the internal medicine intensive care unit (ICU) and the Anesthesiology ICU determined that laboratory examinations were performed more frequently in the internal medicine ICU, whereas surgical interventions and consultation requests to other departments were performed more frequently in the anesthesiology ICU23. It should be noted that there is no easy, uniform method for cost analysis. Intensive care physicians who prioritize patient survival may sometimes consider cost analysis trivial, and may even resist it24. A study comparing the effects of minimal-flow and low-flow anesthesia during thyroid or parathyroid surgery revealed lower cost with minimal-flow anesthesia. However, more caution is warranted due to the risk of a partial decrease in antioxidant parameters25. Therefore, medical complications should be considered when evaluating anesthesia costs.

A study comparing the costs of patients undergoing general (GA) and spinal anesthesia (SA) up until discharge found that GA patients had higher costs. Specifically, anesthesia management costs were higher under GA than under SA. This is likely due to higher preoperative and postoperative care costs for GA patients. The cost of medications required for SA was found to be lower than that required for GA patients26. Although SA is simple, inexpensive, and easy to learn, with a high success rate, it has disadvantages, including hypotension and a high incidence of headaches due to dural perforation27. In the hands of an experienced operator, the LMA achieved high placement success rates, particularly among unselected patients. Notably, accurate placement rates were nearly 100%, and complications were rare28. In our study, the placement rate was 100%. A retrospective study of 542 patients who underwent lumbar discectomy and laminectomy revealed that SA had lower operating, indirect, and total costs compared with GA. Furthermore, a shorter hospital stay, shorter anesthesia and surgery times, and lower estimated blood loss contributed to the reduced SA costs29. Another study found that balanced anesthesia using esmolol for patients undergoing nasal surgery was less expensive than total intravenous anesthesia (TIVA) using propofol30. A comparative study of GA and regional anesthesia (RA) costs in patients undergoing carotid endarterectomy found that operating room costs, postoperative resources, and hospital stays were lower for those undergoing RA31. Toward the end of the last century, the appropriate use of healthcare resources gained significance globally. A study conducted in our country reported that patients scheduled for elective surgery after routine examinations could positively impact their family and country's budgets if they chose to undergo surgery in their city or local area32.

Despite robust findings favoring the overall cost-effectiveness and efficiency of LMA and ETT in many contexts, gaps remain in their use. Future research should focus on the impact of strict single-use policies versus high-reuse policies on true long-term cost-effectiveness, comparative effectiveness and costs in high-risk populations or complex surgeries, and real-world barriers to widespread adoption given institutional procurement practices.

Limitations

Our study has certain limitations. Since it is a single-center study, its results cannot be generalized. Since the type of anesthesia was decided jointly by the consulting faculty member and the specialist physician based on the surgical procedure to be performed, patients could not be randomized. This situation could be considered a potential source of selection bias. The cost of purchasing the materials used may differ depending on each hospital's financial conditions. Additionally, the drugs and treatments used can vary by hospital, leading to cost differences. Operating room practices, patient acceptance criteria, patient characteristics, and cost analysis methods may also differ among hospitals. A more comprehensive cost analysis could not be performed because LMA sterilization, oxygen/nitrogen consumption, and physician/staff costs were not included in the study.

Conclusion

Based on the direct material and medication cost data obtained in our study, we determined that using an endotracheal tube may be more cost-effective than using a laryngeal mask. However, this study did not evaluate important clinical factors such as patient comfort, hemodynamic stability, and postoperative complications. Therefore, it would be incorrect to conclude that the endotracheal tube is entirely "more advantageous" based solely on cost. When making decisions regarding medical supply preferences, hospital administrators and clinicians should use a comprehensive approach that considers not only cost analyses but also patient-specific clinical outcomes and comfort.

Author Contributions: Y.O.: Conceptualization, Investigation, Writing. F.B.B.: Investigation, Data collection. H.K.: Data analysis, Writing, Editing. M.C.: Writing, Editing.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Institutional Review Board Statement: This study was approved by the Kahramanmaraş Sütçü İmam University Faculty of Medicine Clinical Research Ethics Committee on July 25, 2018 (No: 2018/13-27). The study was conducted in accordance with the principles of the Declaration of Helsinki.

Informed Consent Statement: Written informed consent was obtained from all patients.

Acknowledgments: The authors would like to thank Enago (www.enago.com) and DeepL for their English language review services, and İstar Consulting – Statistics and Research Center for the statistical analysis.

Conflict of Interest: The authors declare that they have no competing interests.

Data Availability Statement: Readers can contact the authors if further information is required.

genAI: No artificial intelligence-based tools or generative AI technologies were used in the preparation of this manuscript. The entire content of the manuscript was originally prepared, reviewed, and approved by all authors.

Congress Presentation: This study was presented as an oral presentation at the 10th International Congress on Healthcare Management, December 11–14, 2019, Antalya, Türkiye.