JSAN 2016; 3 (2)

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ANESTHESIOLOGISTS OF NEPAL
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Journal of Society of Anesthesiologists of Nepal

JSAN Volume 3, Issue 2, September 2016
ISSN 2362-1281

Journal of Society of Anesthesiologists of Nepal 77

Original Article
Randomized clinical trial of trapezius squeezing test and jaw thrust as
optimal indicators for Laryngeal mask airway insertion in adults under
propofol anesthesia
Sushil Khanal, Bibhush Shrestha, Roshana Amatya, Moda Nath Marhatta

Grande International Hospital, Tokha Road, Kathmandu 44600, Nepal

Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu 44600, Nepal

Abstract
Background: Laryngeal mask airway insertion requires a certain depth of anesthesia
that blunts the airway reflexes. We compared the effectiveness of the trapezius
squeezing test with that of the jaw thrust test as clinical indicators of adequate
condition for laryngeal mask airway insertion in adults under propofol anesthesia.
ARTICLE INFO
Article History Methods: In this randomized study, seventy adult patients undergoing surgery with
Received 05.03.2016 general anesthesia maintained with laryngeal mask airway were randomly allocated
Accepted 23.07.2016 to the group T (trapezius squeezing, n = 35) or the group J (jaw thrust, n = 35). The
Published 17.09.2016 laryngeal mask airway was inserted immediately after the loss of response to trapezius
Authors retain copyright squeezing or jaw thrust. We recorded successful and unsuccessful attempts. An
and grant the journal right of unsuccessful attempt was defined as development of coughing, SPO2 < 90%, body
first publication with the work movements during or within one minute of laryngeal mask airway insertion and
simultaneously licensed under failed insertion of laryngeal mask airway. Preparation time for laryngeal mask airway
Creative Commons Attribution insertion, blood pressure, and heart rate were recorded.
License CC - BY 4.0 that allows Results: The incidence of successful attempts was significantly higher in the group T
others to share the work with than in the group J (p-value = 0.002). The time taken for preparation and insertion
an acknowledgement of the of laryngeal mask airway, arterial blood pressure and heart rate were comparable in
works authorship and initial both the groups.
publication in this journal.
Conclusion: This study has demonstrated that the trapezius squeezing test is a
superior indicator of an adequate condition for laryngeal mask airway insertion
compared to the jaw thrust test in adults.
Keywords: adult; general anesthesia; laryngeal mask airway; supraglottic airway
devices; propofol

Prior presentation: This paper was presented at the 15th National conference of Society of Anesthesiologists of Nepal
in March 2014.
How to cite this article: Khanal S, Shrestha B, Amatya R, Marhatta MN. Randomized clinical trial of trapezius squeezing
test and jaw thrust as optimal indicators for Laryngeal mask airway insertion in adults under propofol anesthesia. Journal
of Society of Anesthesiologists of Nepal (JSAN) 2016;3(2):64-68. http://dx.doi.org/10.3126/jsan.v3i2.15610

Corresponding Author: Dr. Sushil Khanal, MD

Anesthesiologist, Grande International Hospital, Tokha road, Dhapasi, Kathmandu 44600, Nepal
Email: [email protected]

64 Journal of Society of Anesthesiologists of Nepal

 JSAN 2016; 3 (2)
Introduction In the operating theater, pulse oximetry, electrocardiogram,
noninvasive arterial blood pressure were attached and
Laryngeal mask airway (LMA) have become an integral
recorded (Baseline).
part of anesthetic care in airway management.1 Adequate
depth of anesthesia is necessary for successful insertion Patients were locally randomized in operating room
of LMA. Lighter planes of anesthesia during LMA insertion into two groups by sealed envelope method: trapezius
can result in coughing, gagging, body movements, breath squeezing test, group T (n=35) and jaw thrust, group
holding, and even rejection of LMA.2 The indicators which J (n=35). After the sealed envelopes were opened by
are used to measure the precise depth of anesthesia consultant anesthesiologist to decide for patients'
should be simple, repeatable, and accurate maneuver allocation, the investigator was then informed to perform
to perform.3 Various such indicators are loss of verbal the test.
contact, eyelash reflex, corneal reflex, loss of ability to
Preoxygenation was done via face mask with oxygen at
hold light object, jaw relaxation, apnea, and jaw thrust
5 liters/min for three minutes. After preoxygenation,
maneuver.2-4 An alternative indicator such as trapezius
propofol 10 mg intravenously was given to the patient
squeezing test has been suggested as a useful indicator for
every five seconds until the negative test to either
LMA insertion.3
trapezius squeezing test or jaw thrust test, performed at
Trapezius squeezing test is a clinical test simple to perform intervals as described below. In the group T, as soon as
in which 12 inches of full thickness trapezius muscle is the patient lost verbal contact the trapezius squeezing
held and squeezed for 1-2 seconds and response evaluated test was performed by squeezing the full thickness
in the form of toe or body movement. A negative response trapezius muscle for 1 to 2 seconds. Trapezius squeezing
to trapezius squeeze is depicted by the loss of toe or body test was done every ten seconds till it became negative.
movement Trapezius squeezing test is free of side effects, In group J, the jaw thrust was done by grasping and lifting
repeatable and reproducible.2 Although used extensively the angles of the lower jaw with both hands, one on
for grading consciousness; this test has rarely been used each side, while displacing the mandible forward. The
and studied as an indicator of the adequate depth of jaw thrust test was done every ten seconds till it became
anesthesia for LMA insertion. negative. After a negative response to trapezius squeezing
or jaw thrust test as determined by attending consultant
Till date, no study has been done comparing trapezius
anesthesiologist, a well lubricated, appropriate size
squeezing test and jaw thrust for assessing the depth of
classic LMA according to body weight was inserted. All
anesthesia under intravenous propofol. This may be a
laryngeal mask insertion and the tests were performed
pioneer study comparing trapezius squeezing test and
by the same investigator.
jaw thrust under propofol anesthesia in adult as clinical
indicators of an adequate condition for LMA insertion. The response of the patient to LMA insertion was
classified as either successful or unsuccessful attempt
Methods
by consultant anesthesiologist. Successful attempt was
This prospective, randomized, single-blinded, comparative identified if there was no coughing, SPO2 90%, absence
study was conducted over a period of four months at of body movement during or within one minute of LMA
Tribhuvan University Teaching Hospital (TUTH). The study insertion. Development of coughing, SPO2 < 90%, body
was approved by institutional Ethical committee. movements during or within one minute of LMA insertion
Seventy adult patients of age 18 to 65 years with ASA and failed insertion of LMA was regarded as unsuccessful
physical status I/II in whom anesthesia can be maintained attempt. The preparation time for LMA insertion was
in spontaneously breathing condition with an LMA were measured from propofol administration to the negative
included in the study. Patients with predicted difficult trapezius squeezing test or jaw thrust test. Effective
airway, risk of aspiration, acute respiratory infection, ventilation and correct alignment of LMA was determined
psychiatric illness and allergic to propofol were excluded by observing chest wall movement, auscultation, and
from the study. capnography. Heart rate, blood pressure, and SPO2
were recorded before the induction of anesthesia
The eligible patients were evaluated prior to surgery (baseline), immediately after the negative response to
(pre-anesthetic check up). Written informed consent was test (preinsertion) and one minute after LMA placement
taken. Age, sex, and weight of the patient were recorded. (postinsertion).
The patient was kept nil per oral at least 6 hrs prior to
surgery. Premedication was given 2 hrs prior to surgery Coughing during LMA insertion was graded in the following
(Tab diazepam 5mg for weight <50 kg, 10mg for weight> manner.5
50 kg). In the preoperative room, intravenous access was 1- None.
secured with an 18 G cannula and IV drip was started with
2- Less than or equal to two coughs.
Ringers lactate.

Journal of Society of Anesthesiologists of Nepal 65

 JSAN 2016; 3 (2)
3- More than two coughs. Table 1: Demographic distribution
The patients body movement during LMA insertion was
graded as follows.6 Group J Group T p
Parameter
(n = 35) (n = 35) value
1- None.
2- Slight movement of the upper and/or lower extremities. Mean
Age(yrs) 31.7 12.1 29.8 10.67 0.486
3- Moderate movement including the trunk.
SD
4- Failed insertion of the LMA with a marked movement Male 20 (57%) 19 (54%)
LMA, if could not be inserted at the first attempt after a Gender 0.810
Female 15 (43%) 16 (46%)
negative test, the patient was further managed accordingly
at the discretion of consultant anesthesiologist. However, Mean Body
the condition during LMA insertion was only graded Weight (kg) 57.05 9.19 57.9 7.5 0.671
at the first attempt. After LMA insertion, anesthesia SD
was maintained with oxygen, isoflurane and fentanyl at Table 2: Incidence of Coughing and Movement
1-2mcg/kg.
Parameter Grade Description Group Group p
Hemodynamic values were recorded before the induction J(n=35) T(n=35) value
of anesthesia (baseline), immediately after the negative
Cough 1 No cough 20 29 0.019
response to test (preinsertion) and one minute after LMA 2 2 cough 7 4
placement (postinsertion). 3 >2 cough 8 2
The primary outcome measure of the study was to Movement 1 None 25 31 0.023
assess the response of the patient to LMA insertion as 2 Slight movement 4 4
a successful or unsuccessful attempt. The preparation of upper and lower
time, heart rate and blood pressure were secondary extremities
outcome measures of the study. The sample size was 3 Moderate 5 0
worked out as total 70 patients to achieve significance to movement
be between 80% and 50 % success rates at a level of p< including trunk
0.05 and power of 0.8. Data were collected in preformed 4 Failed insertion of 1 0
data collection sheet and were analyzed using statistical LMA with marked
package for the social sciences (SPSS) software version 20 movement
using appropriate statistical tests. Independent samples
Table 3: Response to LMA insertion
test was used for analysis of age wise distribution,
weight wise distribution, preparation time taken for LMA Response Group J Group T p value
insertion and hemodynamic parameters. Chi-Square (n = 35) (n = 35)
test was used for analysis of gender wise distribution, Successful insertion 14 (40%) 27 (77%) 0.002
the incidence of a cough and movement and response
to LMA insertion. A p-value of < 0.05 was interpreted as
statistically significant. Unsuccessful insertion 21 (60%) 8 (33%)

Results
All patients remained hemodynamically stable during the
Demographic data were comparable in both the groups procedure.
(Table 1). The differences between two groups with Discussion
respect to the incidence of a cough (p = 0.019) and
Assessment of the depth of anesthesia is fundamental
body movement (p = 0.019) were statistically significant
to anesthetic practice. One of the objectives of modern
(Table 2). There was unsuccessful insertion of LMA anesthesia is to ensure adequate depth of anesthesia
in 21 patients in group J and 8 patients in group T. The without overdosing the patients with potent drugs. There
difference between the response to LMA insertion in two appears to be increasing evidence that anesthesia depth
groups was statistically significant (p=0.002) (Table 3). The measurement improves the quality of anaesthesia.7
preparation time taken for insertion of the LMA in group Deep anesthesia is essential to obtund airway reflexes
J was 80.5 19.3 seconds when compared to 81.1 14.6 and hemodynamic responses and for obtaining optimal
seconds in group T and it was not statistically significant conditions for LMA insertion.
(p =0.879).

66 Journal of Society of Anesthesiologists of Nepal

 JSAN 2016; 3 (2)
During LMA insertion airway complications like coughing, test with jaw thrust. Townstead R et al.12 obtained the
gagging, hiccups or aspiration are encountered by optimal condition for LMA insertion in 76% patients with
anesthesiologists.8 However, after the suppression of jaw thrust using fentanyl and propofol as an induction
airway reflexes with adequate anesthesia, LMA can be agent. Similarly, Drage MP et al13 suggested that jaw thrust
inserted smoothly. An ideal method detecting optimal is a reliable marker of successful LMA insertion in adults
anesthetic depth for LMA insertion must be repeatable, with an 87% success rate, which was higher than that in
easy to perform and harmless to the patient. The this study (40%).The reason behind such big difference
assessment of depth of anesthesia during LMA insertion in success rate of jaw thrust may be attributed to the
involves the observation of responses after application of combined use of fentanyl and propofol in their study
the stimulus. Many clinicians use loss of verbal contact whereas our study used propofol only as sole induction
and eyelash reflex or jaw relaxation as a clinical marker of drug. Kodaka et al.14 also demonstrated more success rate
optimal anesthetic depth.4 of LMA insertion with less body movement with propofol-
fentanyl compared to the propofol-saline group.
There have been very few studies 2-4 on trapezius squeezing
test predicting the depth of anesthesia for LMA insertion Trapezius squeezing test, checked by squeezing the
till date. Our study was performed to compare trapezius trapezius muscle and observing the motor response, is
squeezing test and jaw thrust as indicators for laryngeal one of the methods to assess the anesthetic depth during
mask airway insertion in adults. The primary objective LMA insertion. Our study had shown the significantly
of our study was to compare the effectiveness of the higher number of successful insertions of LMA in trapezius
trapezius squeezing test and the jaw thrust, measured in squeezing group as compared to jaw thrust group (77%
terms of successful or unsuccessful insertion. Our study vs. 40%). These observations are comparable to the study
shows that the trapezius squeezing test is a reliable and of Chang CH et al.3 Thus, the trapezius squeezing test had
useful clinical indicator assessing the adequate depth of better predicted the sufficient anesthetic depth for LMA
anesthesia for LMA insertion in adults. insertion preventing complications such as cough and
patient movement.
Successful insertion of LMA requires an adequate depth of
anesthesia either by inhalational or intravenous anesthesia. The Preparation time for LMA insertion as noted from
To date, for LMA insertion, propofol is the intravenous propofol administration to the negative trapezius squeezing
drug of choice as it provides rapid relaxation.9 No study test or jaw thrust test was comparable in both the group.
has been conducted with propofol as induction agent The mean time was 81.1 14.6 (SD) seconds in trapezius
comparing trapezius squeezing test and jaw thrust. All of squeezing group and in jaw thrust group it was 80.5 19.3
the studies have been done with sevoflurane.2-4 Several (SD) seconds (p = 0.879). Preparation time of sixty to ninety
studies have shown that the induction of anesthesia via seconds after routine propofol induction has provided
sevoflurane and propofol are comparable.10,11 Even some excellent placement condition for LMA insertion in study
study has found propofol being superior to sevoflurane for done by Sheu R et al.15 The insertion time from sevoflurane
insertion of the LMA.10 This study may be the first study inhalation induction to LMA insertion when guided by the
to compare trapezius squeezing test and jaw thrust using trapezius squeezing test and jaw thrust test was 4.1 minutes
propofol for LMA insertion. and 2.5 minutes respectively in Chang CH et al.3 study.
The demographic characteristics of the patients in both Shorter time for LMA insertion in our study was due to faster
the jaw thrust and trapezius group were comparable in onset of induction with propofol. There was no evidence of
our study. There was no significant difference in patient laryngospasm, gagging, breath holding reported during the
distribution in terms of age, gender, and weight between insertion time of LMA in both of study groups.
the two groups. Successful LMA insertion requires Both the groups exhibited stable hemodynamic profiles.
attenuation of the hypopharyngeal and laryngeal reflexes.10 In our study we didnt use bolus dose of propofol, this
An adverse response like coughing during LMA insertion could be the reason behind stable hemodynamic seen in
is undesirable. In our study, we have found a significant our patients in both the groups. Stokes et al.16 also noted
decrease in the incidence of a cough in trapezius squeeze that decrease in the rate of administration decreases not
group as compared to jaw thrust group (p = 0.019). This
only the dose of propofol but also the degree of adverse
finding is similar to study done by Chang CH et al3 who
hemodynamic events. Postoperative problems like pain at
compared trapezius squeezing test with jaw thrust test
squeeze site and evidence of trauma like ecchymosis were
using sevoflurane.
not noticed in any group.
Laryngeal mask airway insertion is done without any
Our study has several limitations. First, our findings may
muscle relaxant; however, it requires a sufficient depth
not apply to other insertion techniques (such as the
of anesthesia.6 Body movement during LMA insertion
laryngoscope-guided technique) or other laryngeal mask
can cause rejection of LMA.2 In our study, there was less
airway devices (such as the intubating LMA), as the level
incidence of body movement in trapezius group after
of stimulation may be different. Second, our findings may
insertion of LMA (p = 0.023). A similar result was observed
not apply to other induction agents, particularly those that
by Chang CH et al3 when comparing trapezius squeezing

Journal of Society of Anesthesiologists of Nepal 67

 JSAN 2016; 3 (2)
are less effective at obtunding upper airway reflexes, such children undergoing eye surgery. Indian J Anaesth 2010;54:104-
as thiopentone.17 Third; we did not determine the optimal 8. http://dx.doi.org/10.4103/0019-5049.63641 [PMid:20661346]
level of jaw thrust and the squeezing power for trapezius [PMCid:PMC2900731]
squeezing test. However, all the tests were conducted by 10. Ti LK, Chow MY, Lee TL. Comparison of Sevoflurane with Propofol
a single investigator in order to maintain the uniformity. for Laryngeal Mask Airway insertion in adults. Anesth Analg
Trapezius squeezing test can be used as a reliable and safe 1999;88:908-12. http://dx.doi.org/10.1213/00000539-199904000-
indicator for assessing the depth of anesthesia for insertion 00041 [PMid:10195546]
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Informed consent: Informed consent was obtained from all the
as predictor of insertion conditions of proseal laryngeal mask.
participants included in the study.
Middle East J Anesthesiol 2009;20:59-62. [PMid:19266827]
Funding: Nil
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test to assess the adequate depth of anaesthesia for insertion of
Conflict of interest: No stated conflict of interest among the authors
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68 Journal of Society of Anesthesiologists of Nepal