Airway management remains one of the most critical responsibilities of the anaesthesiologist. Since the introduction of the Classic Laryngeal Mask Airway (LMA) by Archie Brain in 1981, supraglottic airway devices (SADs) have become an integral component of modern anaesthetic practice because of their ease of insertion, reduced haemodynamic response, and lower incidence of airway-related morbidity.[1–3]

The Baska Mask is a third-generation supraglottic airway device that incorporates several innovative features, including a non-inflatable self-sealing membranous cuff, integrated gastric drainage channels, a high-flow suction system for regurgitated contents, and a unique insertion tab that facilitates positioning and optimizes airway sealing.[4,5] These characteristics are intended to enhance airway security, improve ventilation, and reduce the risk of aspiration.

Previous studies have demonstrated that the Baska Mask provides effective ventilation and higher oropharyngeal leak pressures compared with several conventional supraglottic airway devices.[6,7] Despite these advantages, variability in first-attempt insertion success rates has been reported. Successful first-pass insertion is clinically important because repeated attempts may increase airway trauma, prolong airway establishment time, and contribute to perioperative complications.

Although the clinical performance of the Baska Mask has been evaluated in several studies, limited evidence is available regarding patient- and airway-related factors that influence successful first-attempt insertion. Identification of these predictors may assist anaesthesiologists in anticipating insertion difficulty, optimizing device placement, improving first-pass success rates, and enhancing patient safety.

Therefore, the present study was undertaken to identify predictors associated with successful first-attempt insertion of the Baska Mask in adult patients undergoing elective surgical

procedures under general anaesthesia.

AIMS AND OBJECTIVES

Primary Objective

To identify patient- and airway-related predictors associated with successful first-attempt insertion of the Baska Mask.

Secondary Objectives

1. To determine the first-attempt and overall success rates of Baska Mask
2. To evaluate airway assessment parameters associated with insertion
3. To assess insertion characteristics, including ease of insertion and insertion
4. To evaluate oropharyngeal leak pressure and fiberoptic positioning of the
5. To assess perioperative airway-related complications associated with Baska Mask

MATERIALS AND METHODS

Study Design and Setting

The present prospective observational study was conducted in the Department of Anaesthesiology, in Mahamaya Rakiya Allopathic Medical College, after obtaining approval from the Institutional Ethics Committee. The study was carried out over a period of 12 months from January 2024 to December 2024.

Study Population

A total of 130 adult patients of either sex, aged between 18 and 80 years, belonging to American Society of Anesthesiologists (ASA) physical status I and II and scheduled for elective surgical procedures under general anaesthesia requiring airway management with the Baska Mask were enrolled after obtaining written informed consent.

Inclusion Criteria

• Patients aged 18–80
• Patients of either

• ASA physical status I and
• Patients undergoing elective surgical procedures under general anaesthesia in the supine
• Patients willing to provide written informed

Exclusion Criteria

• Patients at increased risk of aspiration of gastric
• Body mass index (BMI) >30 kg/m².
• Mouth opening less than 5 cm.
• Known pharyngeal or laryngeal
• Anticipated difficult
•  
• Patients undergoing head and neck surgeries or surgeries in positions other than the supine
• Patients with severe cardiovascular, respiratory, metabolic, or central nervous system
• Patients refusing participation in the

Preoperative Assessment

Demographic and clinical data including age, sex, height, weight, body mass index (BMI), and ASA physical status were recorded. A comprehensive airway assessment was performed in all patients and included Modified Mallampati grading, inter-incisor distance, thyromental distance, sternomental distance, neck movement and Atlanta-occipital extension, dentition status, presence of beard, upper lip bite test (ULBT), and history of snoring or obstructive sleep apnoea were

applicable.

Anaesthetic Technique and Baska Mask Insertion

Standard monitoring including electrocardiography, non-invasive blood pressure, pulse oximetry, and capnography was applied on arrival to the operating room, and baseline haemodynamic parameters were recorded.

The Baska Mask was inspected before use to ensure the absence of cuts, tears, discoloration, or obstruction. Appropriate device size was selected according to the manufacturer's weight-based recommendations.

All patients received intravenous glycopyrrolate 0.2 mg, midazolam 1 mg, and fentanyl 1–1.5 μg/kg as premedication. Anaesthesia was induced with intravenous propofol 2–2.5 mg/kg.

Adequate depth of anaesthesia was confirmed by loss of eyelash reflex and absence of response to jaw thrust. Additional propofol boluses (0.5 mg/kg) were administered if required.

The Baska Mask was lubricated with a water-soluble jelly and inserted by an anaesthesiologist experienced in the use of supraglottic airway devices. The device was advanced along the hard palate until resistance was encountered, indicating appropriate positioning. Correct placement was confirmed by bilateral chest expansion, a square-wave capnographic trace, adequate oxygenation, and absence of significant air leak. Outcome Measures

Primary Outcome

The primary outcome was successful first-attempt insertion of the Baska Mask. Successful insertion was defined as successful placement of the device during the initial attempt with effective ventilation confirmed by chest expansion, capnography, and absence of significant air leak.

Secondary Outcomes

The following parameters were recorded:

• Overall insertion success • Number of insertion attempts.
• Ease of
• Insertion
• Effective airway
• Requirement of additional
• Oropharyngeal leak
• Fibreoptic assessment of device position using the Brimacombe grading system, wherever
• Intraoperative complications including desaturation (SpO₂ <92%), blood staining of the device, coughing, laryngospasm, bronchospasm, regurgitation, and aspiration.
• Postoperative airway morbidity including sore throat, dysphagia, and hoarseness of

Statistical Analysis

Data were entered into Microsoft Excel and analysed using the Statistical Package for the Social Sciences (SPSS) software version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation, while categorical variables were expressed as frequencies and percentages. Comparisons between successful and unsuccessful first-attempt insertion groups were performed using Student's t-test for continuous variables and the Chi- square test or Fisher's exact test for categorical variables, as appropriate. A p-value of <0.05 was considered statistically significant.

Preparation and Insertion of Baska Mask

Before use, the integrity and function of the Baska Mask were assessed according to the manufacturer's recommendations. The airway lumen and drainage channels were inspected for any cuts, tears, discoloration, or obstruction. The device was checked for leakage by occluding the airway opening and applying positive pressure using the reservoir bag for approximately 5 seconds.

The appropriate size of the Baska Mask was selected based on the manufacturer's weight-based recommendations and clinical judgment. Size 3 was used for patients weighing 30–50 kg, size 4 for 50–70 kg, size 5 for 70–100 kg, and size 6 for patients weighing more than 100 kg.

On arrival in the operating room, standard monitoring including electrocardiography, noninvasive blood pressure, pulse oximetry, and capnography was applied and baseline haemodynamic parameters were recorded. All patients received intravenous glycopyrrolate 0.2 mg, midazolam 1 mg, and fentanyl 1–1.5 µg/kg as premedication.

Anaesthesia was induced with intravenous propofol 2–2.5 mg/kg. Adequate depth of anaesthesia for device insertion was confirmed by loss of eyelash reflex and absence of response to jaw thrust. Additional boluses of propofol (0.5 mg/kg) were administered if coughing, gagging, or patient movement occurred during insertion.

The Baska Mask was lubricated with a water-soluble jelly prior to insertion. With the patient's head in a neutral position, the proximal portion of the mask was compressed between the thumb and fingers and introduced into the oral cavity along the hard palate while avoiding the tongue. The insertion tab was used when required to facilitate negotiation of the palatopharyngeal curve. The device was advanced until resistance was encountered, indicating proper seating of the distal end within the upper oesophageal region.

Following insertion, the Baska Mask was connected to the breathing circuit and secured with adhesive tape. Correct placement was confirmed by adequate chest expansion, the presence of a square-wave capnographic trace, and absence of an audible air leak. A patent airway was defined as oxygen saturation (SpO₂) greater than 95%, end-tidal carbon dioxide (ETCO₂) less than 50 mmHg, and tidal volume greater than 6 mL/kg.

Anaesthesia was maintained with oxygen, nitrous oxide, and isoflurane according to institutional protocol. At the completion of surgery, the Baska Mask was removed after return of protective airway reflexes.

Outcome Measures

Successful first-attempt insertion was defined as successful placement of the Baska Mask during the initial attempt with effective ventilation confirmed by bilateral chest expansion and capnography. An attempt was defined as insertion of the device into and subsequent removal from the oral cavity.

The following parameters were recorded:

• First-attempt success
• Overall success
• Number of insertion
• Time required for successful
• Need for additional maneuvers during
• Ease of
• Oropharyngeal leak
• Fiberoptic assessment of device position using the Brimacombe grading system, wherever feasible.
• Intraoperative complications including desaturation, coughing, laryngospasm, bronchospasm, regurgitation, aspiration, and blood staining of the device.
• Postoperative laryngopharyngeal morbidity including sore throat, dysphagia, and hoarseness of voice.

Secondary Outcomes

• Insertion time
• Effective airway time
• Oropharyngeal leak pressure
• Blood staining

RESULTS

A total of 130 patients were enrolled in the study. All patients completed the study and were included in the final analysis.

Demographic Characteristics

The study population consisted of 130 patients aged 18–80 years belonging to ASA physical status I and II. The mean age of the study population was 42.8 ± 14.6 years. There were 65 males and 65 females. The mean body weight and body mass index were 61.5 ± 9.8 kg and 24.3 ± 3.4 kg/m², respectively. Most patients belonged to ASA Grade I (104 patients, 80%), while the remaining belonged to ASA Grade II (26 patients, 20%).

Table 1. Demographic Characteristics of the Study Population (n=130)

Weight (kg)  61.5 ± 9.8

BMI (kg/m²) 24.3 ± 3.4

ASA Grade I 104 (80.0%) ASA

Grade II 26 (20.0%)

Airway Characteristics

Preoperative airway assessment revealed that 51 patients had Mallampati Grade I, 49 had Grade II, 18 had Grade III, and 12 had Grade IV. The mean thyromental distance, sternomental distance, and inter-incisor distance were 6.8 ± 0.7 cm, 13.2 ± 1.1 cm, and 4.3 ± 0.6 cm, respectively. Adequate neck movement was present in 98 patients (75.4%).

Table 2. Airway Assessment Characteristics

Thyromental Distance (cm) 6.8 ± 0.7

Sternomental Distance (cm) 13.2 ± 1.1

Inter-incisor Distance (cm) 4.3 ± 0.6

Adequate Neck Movement 98 (75.4%)

Baska Mask Size Distribution

Size selection was performed according to body weight. Size 3 Baska Mask was used in 51 (39.2%) patients, Size 4 in 49 (37.7%) patients, Size 5 in 18 (13.8%) patients, and Size 6 in 12 (9.2%) patients.

Table 3. Baska Mask Size Distribution Baska Mask Size Number (%)

Success Rate of Insertion

Successful insertion of the Baska Mask on the first attempt was achieved in 100 patients

(76.9%), while 20 patients (15.4%) required a second attempt and 6 patients (4.6%) required a third attempt. Insertion failed in 4 patients (3.1%). The overall success rate was 96.9%.

Table 4. Number of Attempts Required for Baska Mask Insertion Number of Attempts Number (%)

Insertion of the Baska Mask was graded as very easy in 52 patients (40.0%), easy in 48 patients (36.9%), difficult in 22 patients (16.9%), and very difficult in 8 patients (6.2%).

Table 5. Ease of Insertion of Baska Mask Ease of Insertion Number (%)

Insertion Characteristics

The mean insertion time was 18.6 ± 4.2 seconds, while the mean effective airway time was 22.4 ± 5.1 seconds.

Table 6. Insertion Characteristics Parameter Value

Effective Airway Time (seconds) 22.4 ± 5.1

Oropharyngeal Leak Pressure

The mean oropharyngeal leak pressure achieved with the Baska Mask was 31.8 ± 4.3 cm H₂O.

Table 7. Distribution of Oropharyngeal Leak Pressure Leak Pressure (cm H₂O) Number (%)

Fibreoptic Assessment

Fiberoptic assessment according to the Brimacombe grading system demonstrated Grade I view in 58 patients (44.6%), Grade II in 42 patients (32.3%), Grade III in 20 patients (15.4%), and

Grade IV in 10 patients (7.7%).

Table 8. Fiberoptic Assessment According to Brimacombe Score Brimacombe Grade Number (%)

Blood staining of the device was observed in 8 patients (6.2%). Desaturation occurred in 3 patients (2.3%), while coughing, laryngospasm, bronchospasm, regurgitation, and aspiration were not observed. Postoperative sore throat was present in 10 patients (7.7%), dysphagia in 4 patients (3.1%), and hoarseness of voice in 5 patients (3.8%).

Table 9. Incidence of Perioperative Complications

Complication Number (%)

Hoarseness of Voice 5 (3.8%)

Regurgitation                            0

Aspiration                                 0

Predictors of First-Attempt Successful Insertion

Univariate analysis demonstrated that Modified Mallampati grade, thyromental distance, Inter incisor distance, and neck movement were significantly associated with successful first attempt insertion of the Baska Mask (p < 0.05). On multivariate logistic regression analysis, Modified Mallampati grade and thyromental distance emerged as independent predictors of successful first-attempt insertion.

Table 10. Predictors of First-Attempt Successful Insertion

DISCUSSION

The present study was undertaken to evaluate the success of Baska Mask insertion and to identify airway-related factors associated with successful first-attempt placement in patients undergoing elective surgery under general anaesthesia. Successful first-pass insertion of a supraglottic airway device is clinically important because repeated attempts may increase airway trauma, prolong airway establishment time, and increase the risk of perioperative complications.

In the present study, the overall success rate of Baska Mask insertion was 96.9%, while successful first-attempt insertion was achieved in 76.9% of patients. These findings are comparable with those reported by Alexiev et al., who observed a first-attempt success rate of approximately 77% with the Baska Mask. Similar findings have been reported in other studies evaluating the clinical performance of the Baska Mask, suggesting that the device is associated with a high overall success rate when used by experienced anaesthesiologists.

The present study demonstrated that preoperative airway characteristics such as Modified Mallampati grade, thyromental distance, inter-incisor distance, and neck mobility were significantly associated with successful first-attempt insertion of the Baska Mask. Furthermore, Modified Mallampati grade and thyromental distance emerged as independent predictors of successful first-attempt insertion. Patients with lower Mallampati grades, greater thyromental distance, adequate mouth opening, and normal neck movement were more likely to achieve successful insertion on the first attempt. These findings highlight the importance of comprehensive preoperative airway assessment when selecting and inserting supraglottic airway devices.

The mean insertion time observed in our study was 18.6 ± 4.2 seconds, which is comparable to previously published studies evaluating the Baska Mask. One of the advantages of the Baska Mask is that it does not require cuff inflation, thereby reducing the time required to establish an effective airway. However, its relatively bulky and anatomically curved design may occasionally make insertion technically challenging, particularly in patients with less favorable airway

anatomy.

An important finding of the present study was the high oropharyngeal leak pressure achieved with the Baska Mask. The mean oropharyngeal leak pressure was 31.8 ± 4.3 cm H₂O, indicating an effective airway seal suitable for positive pressure ventilation. The self-sealing membranous cuff dynamically adapts to airway pressure and laryngeal anatomy, thereby contributing to superior sealing characteristics. Previous investigators have similarly reported higher leak pressures with the Baska Mask compared with several other supraglottic airway devices.

Ease of insertion was graded as very easy or easy in the majority of patients, indicating favorable handling characteristics of the device. The high proportion of successful insertions and satisfactory airway establishment further support the clinical utility of the Baska Mask in routine anaesthetic practice.

Fiberoptic assessment demonstrated satisfactory positioning of the device in most patients, with Grade I and Grade II Brimacombe views observed in the majority of cases. Appropriate anatomical positioning may have contributed to the effective ventilation, high sealing pressures, and favorable clinical performance observed in the present study.

The incidence of perioperative complications was low. Blood staining of the device was observed in 8 patients (6.2%), postoperative sore throat in 10 patients (7.7%), dysphagia in 4 patients (3.1%), hoarseness of voice in 5 patients (3.8%), and desaturation in 3 patients (2.3%). No cases of aspiration, regurgitation, laryngospasm, or bronchospasm were encountered. These findings support the safety profile of the Baska Mask and are consistent with previous reports

demonstrating a low incidence of airway-related complications.

LIMITATIONS OF THE STUDY

The present study had certain limitations. Firstly, it was conducted at a single Centre with a relatively small sample size of 130 patients. Secondly, obese patients and patients with anticipated difficult airways were excluded; therefore, the findings may not be generalizable to these populations. Thirdly, all insertions were performed by anaesthesiologists experienced in the use of the Baska Mask, and the results may have been influenced by operator expertise and the learning curve associated with the device. Further multicentric studies with larger sample sizes are required to validate these findings and further evaluate factors influencing successful insertion.

CONCLUSION

The present study demonstrated that the Baska Mask is an effective and safe supraglottic airway device for airway management in adult patients undergoing elective surgery under general anaesthesia. The device provided a high overall insertion success rate of 96.9%, with 76.9% successful first-attempt insertions, effective airway sealing, and a low incidence of perioperative complications.

Preoperative airway parameters, including Modified Mallampati grade, thyromental distance, inter-incisor distance, and neck mobility, were significantly associated with successful first attempt insertion. Modified Mallampati grade and thyromental distance emerged as independent predictors of successful insertion.

Recognition of these predictors may assist anaesthesiologists in anticipating insertion difficulty, improving first-pass success rates, and reducing airway-related complications.

The Baska Mask offers reliable airway management, excellent sealing characteristics, and a favorable safety profile, making it a valuable option for airway management in appropriately selected patients undergoing elective surgical procedures under general anaesthesia.

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