Comparison of ventilation with second-generation supraglottic airway devices in a prospective randomized cadaver study

www.nature.com/scientificreports OPEN Comparison of ventilation with second-generation supraglottic airway devices in a prospective randomized cadaver study Frank Weilbacher1, Nikolai Kaltschmidt1, Marita Klein1, Lisa Kaltschmidt1, Harald Genzwürker2, Erik Popp1 & Stephan Katzenschlager1 Second-generation supraglottic airway devices (SADs) are widely used alternatives to endotracheal intubation in both anesthesia and emergency airway management. The newly developed LT®evo represents a redesigned version of the established Laryngeal Tube Suction Disposable (LTS-D). This study compared the ventilatory performance of the LT®evo with endotracheal intubation and three other second-generation SADs— LTS-D, Ambu® AuraGain™ and i-gel® Plus—using a controlled human cadaver model. In this prospective, randomized experiment, six thawed adult cadavers were sequentially ventilated via an endotracheal tube (ET) and four SADs under standardized mechanical ventilation (tidal volume 7 mL/kg, PEEP 5 cmH₂O, respiratory rate 10/min). Airway pressure and flow were continuously recorded (sampling rate 200 Hz) to determine inspiratory tidal volume, pressure, flow, and calculated resistance. Endotracheal intubation using fiberoptics was attempted via LT®evo , AuraGain™ and i-gel® Plus. Data were analyzed using Kruskal–Wallis tests with Holm-corrected posthoc pairwise comparisons. From six human cadavers (60–85kg estimated body weight), 30 complete ventilation datasets were obtained. Initial fiberoptic control of SAD placement showed optimal positioning in 13 of 24 insertions. During ventilation cycles, inspiratory tidal volumes of the LT®evo (0.49 [0.46–0.52]) were similar to those of ET, AuraGain™ and LTS-D and superior to those of the i-gel® Plus (0.31 L [0.27–0.33], p < 0.001). Peak inspiratory pressure and inspiratory resistance were higher in ET when compared to LT®evo and all other SADs. Endotracheal intubation using fiberoptics was successful in all attempts via LT®evo , AuraGain™ and i-gel® Plus. In this controlled cadaver study, the newly designed LT®evo demonstrated ventilatory performance comparable to that of the LTS-D and the Ambu® AuraGainTM and was superior to the i-gel® Plus in delivering adequate tidal volumes. Additionally, LT®evo allowed for fiberoptic ET placement. Importantly, these results are specific to the cadaveric model and reflect technical variability in ventilation mechanics rather than clinical effectiveness. Clinical trial number German Clinical Trials Registry, DRKS00038309, on October 30th, 2025. Keywords Airway management, Supraglottic airway device, Emergency medicine, Laryngeal masks, Laryngeal tubes, Cadaver Supraglottic airway devices (SAD) play a crucial role in airway management, providing an alternative to both bag-mask ventilation and endotracheal intubation in patients of all ages across various clinical scenarios, including emergencies. Various international and national Anaesthesia Guidelines for Airway Management recommend the use of SADs when mask ventilation and/or intubation are expected or found to be difficult or fail1,2. For cardiac arrest, the International Resuscitation Guidelines advise considering the use of supraglottic airway devices for advanced airway management3. Following the introduction of the laryngeal mask airway in 1983 by Archie Brain4, a wide range of supraglottic airway devices has been developed. So-called ‚second generation‘ SADs with improved seal and an additional 1Medical Faculty Heidelberg, Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany. 2Medical Faculty Heidelberg, Heidelberg University, Heidelberg, Germany. email: Scientific Reports | (2026) 16:15873 | https://doi.org/10.1038/s41598-026-53005-5 1 gastric channel are currently recommended, especially for emergency settings in unfasted patients1,2. Some devices can also be used as a conduit for fiberoptic intubation once adequate ventilation is ensured. Whenever new devices are introduced, early evaluation and comparison with currently available products is desirable. The Laryngeal Tube, a reusable silicone device, was first introduced in 20005,6. A first version with a gastric drain channel, the Laryngeal Tube Suction, became available in 20027. The development of paediatric sizes necessitated a redesign of the device, and the trend toward single-use devices led to the LTS-D that has been available since 2005. The new Laryngeal Tube LT®evo (VBM Medizintechnik, Germany) is a completely redesigned version of the LTS-D. The following major design changes have been made: An oval cross-section of the tube and modified shapes of the proximal and distal cuffs are intended to improve positioning. Epiglottis deflectors are designed to reduce the risk of the airway being obstructed by the epiglottis. The ventilation channel has been enlarged and the ventilation opening has been adapted to allow endotracheal intubation via the LT evo using a flexible fiberoptic, which is not possible with the LTS-D. Additionally, softer, more flexible materials have been incorporated. This study aimed to compare ventilation with the newly designed LT®evo to the following well established airway devices: (1) LTS-D as the predecessor of LT®evo and as a laryngeal tube type SAD. (2) Ambu® AuraGainTM (Ambu A/S, Denmark) as a laryngeal mask type SAD with inflatable cuff available since 20148. (3) i-gel® Plus (Intersurgical, United Kingdom), as a laryngeal mask type SAD with a non-inflatable seal composed of a thermoplastic elastomer, first introduced in 20079, with the redesigned version, i-gel® Plus, being introduced in 202110. (4) Endotracheal tube (ET) as the current gold standard of invasive airway management. The feasibility of second-generation SADs for ventilation is of paramount importance for routine clinical use and emergency care. However, there is no data on how LT®evo as a complete redesign compares to currently used SADs and ET with regards to ventilation performance. The present study was designed to fill this knowledge gap by comparing LT®evo against three widely used second-generation SADs and ET in adult cadavers. At the initiation of this study, the LT®evo lacked CE certification; therefore, a cadaveric model was chosen. Methods This was a prospective, randomized, experimental study conducted using a human cadaver ventilation model. Six thawed, non-embalmed human cadavers were used to evaluate ventilatory performance with different airway devices. Each cadaver was thawed at room temperature for two days before the study. All procedures were conducted in accordance with institutional guidelines and German legislation governing the use of post-mortem human tissue in research. Written consent for scientific use was obtained during the donors’ lifetime by the Department of Anatomy at Heidelberg University. This study was approved by the Heidelberg Ethics Committee (S186-2025) on May 8th, 2025, and regist (...truncated)