Classification of supraglottic airways

Early classification and scoring systems for supraglottic airways
In recent years, a number of attempts have been made to categorise supraglottic airways (SADs). In 2004, A Proposed Classification and Scoring System for Supraglottic Sealing Airways: A Brief Review by Miller was published in Anesthesia & Analgesia. This categorised SADs by the sealing mechanism. Three primary groups were identified:

  • Cuffed perilaryngeal sealers – such as the Laryngeal Mask Airway®
  • Cuffed pharyngeal sealers – such as the Cuffed Oropharyngeal Airway (COPA®)
  • Uncuffed anatomically preshaped sealers – such as i-gel®

This classification was further subdivided, so cuffless perilaryngeal sealers could be either ‘directional’ or ‘non-directional’, and cuffed pharyngeal sealers could be designated as ‘with’ or ‘without’ oesophageal sealing. The sealing mechanisms were described in detail, in conjunction with force vectors, frictional force and whether a device was reusable or single-use; or incorporated a mechanism to provide additional protection against aspiration. Whatever the merits of this system, it now appears unnecessarily complex, although to be fair, Miller’s objective was limited to providing a consistent method for evaluating and understanding the mechanisms of action of any given SAD.

In the same paper, Miller provided a provisional scoring of airways, which suggested a number of desirable features appropriate for a SAD for routine use in anaesthesia. This included easy insertion by a non-specialist, stable airway once positioned, sufficient sealing quality to apply positive pressure ventilation, a good first-time insertion success rate, minimal associated risk of aspiration, and minimal risk of cross-infection and serious side effects. These attributes remain valid today, although to this list we could probably now add latex free and atraumatic, requiring minimal training for safe and effective use, incorporation of a bite block, MRI compatibility, and perhaps suitability for use as a conduit for intubation.

International standard for supralaryngeal airways
In 2009, five years after Miller’s paper, the International standard, ISO 11712:2009(E) Anaesthetic and respiratory equipment – Supralaryngeal airways and connectors was published. This standard included five classifications of supralaryngeal designs as follows:

  • Cuffed oropharyngeal airway, where the ventilatory opening is located at the base of the tongue and a sealing surface is located in the oropharynx.
  • Laryngeal masks, where the ventilatory opening is surrounded by the cuff, which forms a seal with the periglottic tissues. The ventilatory opening and the cuff seal usually represent the most distal portion of the device.
  • Pharyngeal or pharyngeal-esophageal tube, where a cuff surrounds the ventilatory tube in a circumferential fashion and is located proximal to the ventilatory opening. This design compartmentalizes the pharynx, with the cuff serving as a sealing divider between the proximal and distal pharyngeal compartments, and the ventilatory opening(s) are located in the distal pharyngeal compartment.
  • Pharyngeal airway liner, which is represented by the streamlined liner pharyngeal airway (SLIPATM). This is a shell-like device that, upon insertion, expands the soft tissues of the neck. The tension of the elastic neck soft tissues that surround the device provides the sealing mechanism. The ventilatory opening is located within the shell in the periglottic area.
  • Device with a soft, gel-like, non-inflatable cuff and widened, concaved buccal cavity stabiliser. The sealing mechanism is created by the soft non-inflatable cuff accurately mirroring the anatomy of the laryngeal inlet to create an impression fit, without the need for cuff inflation.

 This classification did little to reduce complexity.

 1st and 2nd generation devices
In the same year as ISO 11712 was published,  White, Cook and Stoddart, in a review article published in  ‘Pediatric Anesthesia’, entitled, A critique of elective pediatric supraglottic airway devices categorised SADs into 1st and 2nd generation devices. A 1st generation device was described as a ‘simple airway tube’ and 2nd generation as a device that ‘incorporates specific design features to improve safety by protecting against regurgitation and aspiration’. I am not sure if this was the first published description of this method of classification, but its simplicity had immediate appeal, and it quickly became established as the most popular method for classifying SADs.

 It has since been used in numerous published clinical studies, review articles and conference lectures and a number of recommendations regarding use of 2nd generation devices were made in the 4th National Audit Project of the Royal College of Anaesthetists (RCoA) and The Difficult Airway Society (DAS) report, Major complications of airway management in the United Kingdom.

Of course, 2nd generation devices are not all the same, so the clinical evidence for each device regarding safety and efficacy still needs to be reviewed and assessed individually. Designation as a 2nd generation device does not in itself confirm superiority of performance, but the classification does provide useful information about basic product design characteristics, such as whether the device incorporates a mechanism for the management of regurgitant fluid.

In conclusion, although initial classifications of SADs provided some useful information, they were also complex, and as a result never really obtained widespread use or acceptance. The more recent classification of SADs into 1st or 2nd generation devices has proved popular, is widely used and provides valuable information regarding basic product design. Safety and efficacy of individual devices still needs to be reviewed and assessed individually.

A basic diagram highlighting the differences between 1st and 2nd generation devices is shown below (Fig 1). An Infographic, with additional background information, is also available (Fig 2). Please contact me if you would like a pdf copy of the infographic.

Fig 1

Fig 2 – Infographic


5 thoughts on “Classification of supraglottic airways

  1. Pingback: Distinção entre dispositivos supraglóticos de 1ª e de 2ª geração |

  2. Pingback: Use of SADs in the prehospital setting – a new review | Dave on Airways

  3. OK I’m two years late on this article which I just came across
    For info I’ve been using the term 1st and 2nd generation SADs (which I coined) for a few years
    The first publication explaining the classification fully is

    Cook TM, Howes B. Recent developments in efficacy and safety of supraglottic airway devices. Continuing Education in Anaesthesia Critical Care and Pain: 2011; 11: 56-61

    Some people now seem to describe ‘3rd generation devices’ and I even saw one described as 4th generation. Personally I think the classification of SADs could be improved and a collaborative to do this would be good.


    Tim Cook, Bath, UK

    • Tim – thank you for your comments and particularly for confirmation regarding the origin of the term 1st & 2nd generation. A collaborative initiative to provide an improved classification of SADs sounds a great idea. Dave

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