the metablog

Are Health Insurance Premiums the Only Healthcare Cost Keeping Up With Inflation in Australia?

Tue, 15 Apr 2025 06:28:00 +0000

Several questions remain unasked in the ongoing debate about healthcare affordability in Australia.

Why have only private health insurance premiums reliably kept up with inflation among all the major healthcare cost components: doctor’s fees, Medicare benefits, private insurance benefits, government health funding, and public hospital salaries?

Is this true?

Health Insurance Premiums: Always Rising

There’s no debate here: private health insurance premiums have risen almost every single year and nearly always at a rate above the Consumer Price Index (CPI). Over the last 28 years, there have only been six where inflation was higher than the average industry premium increase.

Between 2002 and 2024, private health insurance premiums increased by 5.1% annually, even as inflation averaged almost half that (2.74%) over the same 22-year period. Private insurers justify these increases by pointing to rising treatment costs, increased service use, and an ageing population. While these are all factors, the consistent premium increases have still allowed record profits among the biggest insurers: BUPA, one of Australia's Big Two with Medibank Private, recently reported over AU$ 900 million in profit in the Asia Pacific region.

✅ Conclusion:

Yes, health insurance premium increases have exceeded inflation.

Doctor's Fees and Medicare Benefits: A Growing Gap

Many Australians have noticed it’s getting harder to find a bulk-billing GP. The gap between fees charged and rebates paid continues to widen.

From 2014 to 2020, the Medicare rebate was frozen, despite rising costs.
While doctor’s fees may have risen, they are not indexed, and vary depending on practice location and cost pressures. In fact, most doctors recognise their patient's cost-of-living pressure and have worked hard to keep their fee increases below inflation even as their own practice costs track above the CPI.
The rebate freeze meant that more of the burden was passed on to patients.

❌ Conclusion:

Neither doctor’s fees nor Medicare rebates have reliably kept up with inflation.

Health Insurance Rebates and Benefits: A Two-Speed System

a) Government Health Insurance Rebate (for consumers)

Since 2012, this rebate has: - Been means-tested - Adjusted below inflation

This has reduced its value over time, increasing the cost of private health insurance for many Australians.

b) Private Health Insurance Benefits (payments to doctors/hospitals)

Despite rising premiums: - Benefits paid out by insurers have not kept pace. - Gap payments (out-of-pocket costs) for patients have increased, even as doctors have tried to keep these increases limited while maintaining the financial sustainability of their practices. - Insurers have applied greater scrutiny on what they reimburse.

In my specialty, anaesthesia, most doctors charge well below the AMA's recommended-retail-price for their services. Currently, two-thirds of my own patients receive no out-of-pocket for my anaesthetic care, mostly for high-volume procedures or social circumstances (advanced age, surgical emergencies & complications, miscarriages, financial stress, etc.). The other third of my patients receive a modest out-of-pocket cost, with my total fee still ~50% less than the AMA recommended fee. Because the health insurer benefits paid for anaesthesia services are so low, charging more would dramatically increase the out-of-pocket burden on my patients.

⚠️ Conclusion:

Premiums rise, but the benefits paid rarely match, leading to significant out-of-pocket charges.

Public Funding and Hospital Salaries: Falling Behind

Federal & State Government Funding

Although nominal government spending has increased: - It often lags behind demand growth, inflation, and the growing complexity of care. - Activity-based funding models are frequently criticised for underestimating real costs, although governments favour them because they incentivise efficiency, provide transparency in costs and services, encourage accountability, and align services with health system goals.

Public Hospital Salaries (Doctors & Nurses)

Governed by enterprise bargaining, although annual increases often below CPI.
Many jurisdictions implemented wage caps (e.g. 2.5% in NSW, Victoria) despite inflation above that rate. The current industrial action by NSW salaried doctors is a direct response to hospital wages lagging behind inflation.

❌ Conclusion:

Public hospital funding and salaries have not kept up with inflation or demand.

Australian Health Costs vs Inflation

Category	Kept Up With Inflation?
Health Insurance Premiums	✅ Yes	Often exceeded CPI
Medicare Benefits	❌ No	Frozen for 6 years
Doctor’s Fees	⚠️ Partially	Varies by provider; gaps rising
Government Health Insurance Rebate	❌ No	Adjusted below inflation
Private Health Insurance Benefits	❌ No	Benefits growth slower than premiums
Government Health Funding	❌ No	Not consistently CPI-indexed
Public Hospital Salaries (Doctors)	❌ No	Wage growth < CPI
Public Hospital Salaries (Nurses)	❌ No	Wage caps in place

In recent decades, Australia's healthcare funding landscape has become increasingly uneven. While health insurance premiums have steadily risen, outpacing inflation, other areas have failed to keep pace. As the crisis in maternity care has shown this has significant implications beyond the cost of care: access, equity, and workforce sustainability.

Patients today face a growing financial burden. Out-of-pocket expenses continue to climb in both the public and private systems. The value of Medicare rebates is diminished and bulk billing is less viable for general practitioners. Simultaneously, private health insurance is becoming harder to justify for many Australians. Annual premiums perpetually rise while perceived value is eroded due to coverage limitations and growing gaps between paid benefits and actual service costs.

On the provider side, the pressures are no less acute. Public hospital doctors and nurses have experienced years of effective wage stagnation, with pay increases often failing to match inflation. Coming off the tail of COVID trauma, this slow erosion in real income further affects morale, hampers recruitment and retention, and threatens the long-term stability of the health workforce. When healthcare professionals are underpaid and overstretched, the consequences ripple outward to affect patient care and system efficiency.

In Australia, among various healthcare cost components, health insurance premiums have most consistently increased at or above inflation. Meanwhile other areas, including Medicare and insurance rebates, public hospital funding, and frontline staff salaries, have lagged significantly behind.

What’s needed is healthcare funding that ensures inflation-adjusted support across the system, restores value for patients, and properly recognises the contribution of healthcare workers. We already have care models in Australia that are both lower-cost and higher-quality than the alternatives – this isn't rocket surgery! Only with more sustainable funding can the Australian health system continue to provide accessible, high-quality care into the future.

References

Average annual price changes in private health insurance premiums (Dep. of Health & Aged Care) https://www.health.gov.au/resources/publications/average-annual-price-changes-in-private-health-insurance-premiums
Australian Competition & Consumer Commission (ACCC). Private Health Insurance Reports
https://www.accc.gov.au/publications/private-health-insurance-reports
Australian Inflation Rates: 1949 to 2025 (rateinflation.com) https://www.rateinflation.com/inflation-rate/australia-historical-inflation-rate/
70 Years of Inflation in Australia (ABS) https://www.abs.gov.au/statistics/research/70-years-inflation-australia
Duckett, S., & Breadon, P. (Grattan Institute). Medicare’s Midlife Crisis (2016).
https://grattan.edu.au/report/medicares-mid-life-crisis
Australian Medical Association (AMA). General Practice in Crisis: Rebate Freeze Impact.
https://www.ama.com.au
Private Health Insurance Ombudsman. State of the Health Funds Report (2022).
https://www.privatehealth.gov.au
Australian Medical Association. The Impact of Health Fund Gaps and Policies.
https://www.ama.com.au/articles/gaps-and-value
Productivity Commission. Report on Government Services – Health Sector (2023).
https://www.pc.gov.au/research/ongoing/report-on-government-services
Australian Nursing and Midwifery Federation. Wage Campaigns and EBA Outcomes.
https://www.anmf.org.au
Grattan Institute. Budget Pressures on Public Hospitals.
https://grattan.edu.au
Morton, Rick. Walking wounded: Inside the NSW doctors’ strike. The Saturday Paper. 12 April, 2025. https://www.thesaturdaypaper.com.au/news/health/2025/04/12/walking-wounded-inside-the-nsw-doctors-strike

Australia's maternity crisis: the unasked question

Sat, 12 Apr 2025 08:02:00 +0000

The proposal

Private Healthcare Australia (PHA) CEO Rachel David advocates for a "bundled care" maternity costing model where midwives, GPs, and obstetricians offer fixed-cost maternity packages. This model promises low-cost, full-transparency care across antenatal visits, delivery, and postnatal care – supposedly providing affordable options by allowing private midwives and GPs to manage low-risk pregnancies independently, in parallel with specialist obstetricians funded by the same bundled care model.

The hidden agenda

The critical question remains unasked: Why is the PHA, representing Australia's largest health funds (98% of the market, predominantly for-profit insurers), pushing so aggressively for this model? What benefits do PHA members, such as BUPA, which recently reported over AUD$900 million in profit in the Asia Pacific, have in strongly advocating for this funding model?

David's argument hinges on the uncited claim that only 14% of deliveries require an obstetrician, contradicting the Australian government's own data. Official AIHW statistics show delivery mode alone dictates that over 50% of births require specialist obstetricians before even considering complications like haemorrhage, perineal trauma or retained placentas.

The inevitable sequela

This bundled care model would trigger devastating consequences. Private maternity hospitals will not accept the legal liability of allowing midwives or GPs to deliver independently in their facilities, especially when private midwives are unable to obtain commercial liability insurance for intrapartum care. Even ignoring legal liabilities, what happens when the majority of births require clinical intervention beyond what these practitioners can provide?

Private obstetricians will withdraw from this unsustainable model. Anaesthetists and paediatricians, apparently unpaid under this framework, will decline participation. Few of these specialists will be willing to become involved in these compromised cases.

Over 50% of women requiring obstetricians and the 33% needing epidural analgesia will instead transfer to public hospitals to become public patients in order to access specialist care – no longer costing their private insurer, and losing the continuity of care this model champions. (A continuity of care currently provided by private obstetricians!)

26% of Australian babies are delivered in private hospitals. Shifting even half of these deliveries to the public system will overwhelm already stretched public maternity services, creating a genuine national crisis.

The economic reality

This capped model is economically unviable for private obstetric practices. This is not about "insufficient profit" rather, it's about businesses forced to operate at losses. Obstetric fees represent revenue covering rent, staff, midwives, nurses, ultrasound machines, other equipment, and 24/7 on-call coverage – resources essential for quality care.

Private obstetricians will instead shift practice to gynaecology and fertility. Sadly, private obstetrics will survive only in a handful of capital cities for a wealthy few willing to pay tens of thousands in out-of-pocket fees.

The safest option dismantled

The greatest tragedy? This proposal will dismantle Australia's safest maternity care model. Recent Australian research shows that babies born in the public system suffer double the mortality rate compared with private obstetric care, along with significantly higher rates of maternal haemorrhage, birth trauma and emergency caesareans. Surprisingly, this higher-quality private care was actually AU$ 5,888 less expensive per pregnancy than care in the public system.

The endgame becomes clear: private obstetrics ends. Private midwifery and GP obstetrics will shift the costly part of maternity care – deliveries and emergencies – back to public hospitals paid for by state governments. Meanwhile, the private health funds will successfully rebate vastly smaller amounts while collecting ever-increasing premiums, protecting their record profits at our maternity system's expense.

As we consider changes, we must ask: who truly benefits, and at what cost to mothers and our health system?

Experts Embrace Uncertainty

Mon, 24 Feb 2025 08:37:12 +0000

As we witness the global consequences of expertise rejection, particularly in the United States, I've been considering what truly characterises expertise beyond just specialist domain knowledge and experience – a question at the heart of anaesthesia and critical care practice.

Many doctors are first drawn to anaesthesia as a specialty because we desire control. We imagine ourselves controlling airways, physiology, and pharmacological interactions – sometimes, we even fancy we have some control over our surgical colleagues.

Yet we don't actually control any of these things. Instead, we modify, ablate, and amplify, working within a complex interaction between the patient, physiology, surgery, and our interventions. Our expertise lies not in absolute control but in understanding and adapting to uncertainty.

As news from the US shows a country embracing the "find out" phase of cascading bad decisions (some people just need to touch the stove to learn it's hot), a culture of expertise rejection dominates. This rejection exposes itself in curious ways, including assumptions that success in one field, say, building electric cars or reusable rockets, represents translatable expertise to other specialist fields.

The world is one of shades of grey, and anaesthesia is no different. Embracing uncertainty requires being comfortable with the potential for change and then preparing for and adapting to this change. Anti-experts respond to uncertainty by asserting their will onto reality, mistaking their desired outcome for reality itself. We see this in anaesthesia when something is going very wrong, yet an overwhelmed anaesthetist is unwilling to accept the situation and continues to try the same futile intervention. Airway emergencies particularly highlight this risk.

While many of the world's biggest challenges require cross-discipline insights, humility is essential lest we mindlessly dismantle Chesterton's fences, letting the monsters inside escape. We must accept uncertainty when we lack expertise and learn why the bloody fences are there before we recklessly tear them down.

Aside from their casual callousness and banal cruelty, these anti-experts are dominated by their infallible certainty. In contrast, true experts are intellectually humble, even when they are sure—perhaps especially when they are sure.

Today, we find ourselves at a local maxima of peak uncertainty. Another pandemic is brewing in North America, spreading through poultry and dairy cows, with 15% of the US chicken population already culled. Global economic uncertainty is at a 30-year high, greater than the beginning of the COVID pandemic and now fuelled by wars in Europe and the Middle East. All this while the US toys with authoritarian descent, making me wonder whether the lasting legacy of the country of Washington and Lincoln will be to serve as a warning to future generations.

The expert's approach to uncertainty cannot be passive acceptance or paralysis. Instead, uncertainty demands preparation by considering possible outcomes, decision trees, and probabilistic thinking. Rather than falsely believing we can bend reality to our will, true expertise means adapting our responses and behaviour to reality. This combination of preparedness and humility in acknowledging uncertainty defines the expert's mindset and shows why expertise remains crucial for navigating our complex world.

The Unseen Anaesthetist

Mon, 30 Dec 2024 04:35:00 +0000

A grim discontent with healthcare in many Western countries is intensifying, exposing cracks in a strained system.

The recent murder of a US health insurance CEO, along with the dark wave of public sympathy for the assailant, warns us that health system inequity and failure may culminate in extreme ways.

Australia faces its own challenges: escalating medical costs and burdened public and private hospitals, even as international healthcare corporations post record profits. The growing corporatisation of healthcare, driven by insurance companies and hospital conglomerates, is a concerning glimpse of one possible future for medical care. A significant portion of Australian healthcare funding now leaves our shores for these international corporations and their shareholders.

Yet media coverage presents an unbalanced narrative. While corporate healthcare profits receive measured reporting, medical practitioners face scrutiny and criticism, frequently without evidence. I wrote the piece below in response to a two-year media campaign suggesting widespread billing fraud among Australian doctors, particularly anaesthetists and surgeons. Much of this reporting revealed misunderstandings of the health system and medical billing while ignoring how such stories serve corporate healthcare interests, even as the same corporations encourage attacks on doctors from the sidelines.

I submitted this op-ed to several Australian media outlets, but it remains unpublished. I'm sharing it here to contribute to a balanced understanding of the role of medical professionals in Australian healthcare.

Trust is the foundation of anaesthetic care

In our first five minutes together, I must become the most trusted stranger in your life. It was 3 AM, and I was the on-call anaesthetist covering two private maternity hospitals in one of Australia's capitals, meeting a first-time mother who needed an emergency caesarean section. Despite the early hour and my tiredness, this young family's day had been longer. A mix of excitement, exhaustion, fear and hope – and now this couple must trust a stranger at one of life's most vulnerable and significant moments.

Despite her anxiety, we quickly built rapport: kind words, gentle reassurance, and a joke with her nervous partner about how he, too, will need a catheter once we get started. Despite the connected leads, the rhythm of monitors and my spinal anaesthetic, we transformed an emergency into something approaching "normal", even celebratory, a testament to the efficient work of our team. What was routine for us is a singular, life-changing moment for this young couple. Our team worked hard to maintain the balance of safety while delivering a positive, memorable experience.

One of the paradoxes of our work is that anaesthetists practice in a unique space where excellence frequently means invisibility. I often tell patients that the best anaesthetic is the one they don't remember having. While this is neither always desirable nor even possible, the look of disbelief when a patient smoothly wakes up to be told surgery is already complete, can be the greatest reward. Yet this excellence — this practised invisibility — makes our contribution hard to value or understand.

The value of this invisible excellence is substantial. In Australia, 39% of babies are delivered by caesarean section – and all of these require the careful care of an anaesthetist. Over 4 million anaesthetics are given annually in Australia and New Zealand by 8,000 ANZCA anaesthetists, three-quarters of whom are specialists who have completed over 10 years of medical and specialist training. Many anaesthetists hold multiple postgraduate degrees beyond specialty training, some even PhDs, further driving the quality and excellence of anaesthesia forward.

Australia's anaesthesia safety record ranks among the world's best, built on this demanding training, rigorous standards and peer accountability – excellence that underpins the community confidence in our care. When threats to the reputation and trust of anaesthetists occur, the profession acts decisively. The recent case of a senior anaesthetist's resignation demonstrates not whistleblower suppression but rather our profession actively protecting its integrity and reputation. Similar peer pressure occurs in the rare situation of exploitative billing – we point out and chastise unacceptable professional behaviours when seen.

For our young couple welcoming their first child, the emergency caesarean section proceeded quickly. With practised skill, the obstetrician gently delivered a stunned, floppy baby. The paediatrician, hiding any stress, quickly transformed this flat infant into a squawking, flailing bundle, lifting every heart in the room. In this private medicine setting, the anaesthetist and paediatrician (both on their third emergency caesarean of the night) work independently of the hospital. We navigate the complex decisions about billing for emergency care and balancing patient access with financially sustainable practice, especially given today's cost-of-living pressures.

The recent allegations of widespread Medicare fraud in The Age and ABC News show a fundamental misunderstanding of anaesthetic billing practices. Like many anaesthetists, I accept the insurer's payment as the full fee for many patients (though not all) – what we call 'no gap'. Some anaesthetists deliver all their care as 'no gap'. Others set their fees independently of insurer rebates, resulting in routine out-of-pocket charges. All anaesthetists prioritise transparency: we discuss fees before surgery whenever possible, provide written estimates, and ensure patients understand their likely out-of-pocket costs. This transparency ensures patients are fully informed and involved in their care.

Private specialists decide their billing rates to sustain their practice, not to exploit or profiteer. Fee decisions are grounded in ensuring the financial sustainability of private practices, enabling ongoing access to quality specialist care 24/7. It is relevant that one of the forces driving the surging closure of private maternity units around the country is difficulty accessing emergency anaesthetic and paediatric specialists.

The more significant problem with private medical fees lies not in unsubstantiated allegations of widespread fraud, but in complex and often contradictory Medicare rules combined with indexation that has lagged inflation for over 30 years, impoverishing our health system and undermining patient access. When billing mistakes happen, they are almost always unintentional and just as often to the doctor's disadvantage as benefit.

Yet rather than addressing these system-wide challenges, recent coverage has focused on unfounded allegations of widespread fraud, striking at the heart of the patient-anaesthetist relationship. Casually making accusations of systematic exploitation risks eroding the trust that modern anaesthesia relies upon.

In anaesthesia, we ask patients to surrender their autonomy to a near stranger. We do not demand or take this profound trust - we must earn, protect, and honour it. When misconduct allegations arise, we act decisively because trust, once broken, is nearly impossible to rebuild. And just as oxygen is essential to breathing, trust remains the foundation of safe anaesthetic care.

Opioid-free, AF anaesthesia and LMA atelectasis

Thu, 14 Nov 2024 10:37:00 +0000

Three interesting recent studies looking at specific choices around anaesthetic technique. In the Canadian Journal of Anesthesia, da Silveira reviews the benefits of opioid-free laparoscopic surgery; in the Journal of Cardiothoracic and Vascular Anesthesia, Ford goes deep on the pros and cons of different anaesthetic techniques for AF ablation procedures; and finally in the JCA, Liu reports on a single-centre RCT investigating the beneficial effects of LMAs on atelectasis.

Opioid-Free Laparoscopic Surgery: Less Nausea, Similar Pain Control

An interesting meta-analysis from da Silveira et al. explores whether we can effectively manage minimally invasive abdominal surgery without using opioids - an important question given how common opioid-related side effects are.

This was a comprehensive systematic review and meta-analysis of 26 randomised controlled trials, including 2,025 patients. The researchers specifically compared opioid-free versus opioid-containing anesthesia in minimally invasive abdominal surgeries. They were particularly interested in looking at side effects like PONV and bradycardia, as well as pain control and recovery times.

The results were quite interesting. The authors found that opioid-free anaesthesia:

Reduced PONV by 45% (from 24% to 13% / RR CI 0.40 to 0.74).
Led to slightly lower immediate postoperative pain scores (though not clinically significant).
Required less postoperative opioid use in the first 2 hours.
Showed no difference in recovery room length of stay.
Showed no increase in bradycardia, a previously noted concern when using intraoperative dexmedetomidine.

These findings are consistent with previous meta-analysis, but unique to this study, focus only on laparoscopic surgery, excluding orthopaedics and head & neck surgery included in past analyses.

"Opioid-free anesthesia showed a significant reduction in PONV and a decrease in opioid consumption during the first 2 hr postoperatively, suggesting it can be an alternative to opioid anesthesia in minimally invasive abdominal surgeries."

The (small) reduction in postop pain scores and opioid consumption is particularly notable, supporting the idea that intraoperative opioid may induce acute tolerance postoperatively. (We know this happens with remifentanil above a certain dose)

"A multimodal analgesic approach avoiding opioids with the use of lidocaine, magnesium, and ketamine suppresses impulses from injured nerve fibres and transmission of nociceptive stimuli, and may be able to promote analgesia in the first 24 hr after surgery, while reducing opioid consumption in the early postoperative period. ... Additionally, a2-agonists such as dexmedetomidine may replace opioids in terms of sympathetic stabilization, especially during major surgeries."

While the study captured a large sample size and robust statistical analysis, the authors acknowledge limitations related to study heterogeneity, "the included RCTs used different opioid-free anesthesia strategies and medication regimens".

Da Silveira and team make a strong argument for the possible superiority of opioid-free anaesthesia for laparoscopic surgery, it's worth noting that successful use of the technique requires expertise in using alternative agents like dexmedetomidine, ketamine, and regional techniques. The benefits, particularly in reducing post-operative nausea and vomiting, may be worth the learning curve.

Modern Anaesthesia and AF Ablation: What's Best?

This narrative review by Ford et al. examines the impact of anaesthetic technique on the success of catheter ablation for atrial fibrillation (AF), particularly ventilation strategies. It has relevance given that AF's is the most common arrhythmia, leading to a surge in ablation procedures.

The authors examine three key areas: general anaesthesia (GA) vs conscious sedation, high-frequency jet ventilation (HFJV), and high-frequency low tidal volume ventilation (HFLTV).

They show that GA appears superior to conscious sedation, with one study showing 88% vs 69% arrhythmia-free rates at 17 months. The GA group also experience a lower rate of pulmonary vein reconnection and shorter procedural and fluoroscopy times.

Both HFJV and HFLTV show promise in improving catheter stability and procedural outcomes. The authors note:

"GA has been shown to decrease the movement of catheter tips compared to conscious sedation, enabling better stability and lesion formation."

Though they acknowledge that HFJV faces practical challenges:

"While HFJV is known for its positive impact on catheter stability, its implementation faces challenges such as high costs, the need for additional training to use the ventilator, and the inability to measure end-tidal CO2."

HFLTV might thus offer a practical middle ground between conventional ventilation and HFJV, potentially providing similar benefits without the extra cost and training demands.

The benefits of GA, HFJV and HFLTV arise from reduced respiratory variability, leading to:

Minimising left atrial movement.
Better catheter stability, improving procedural accuracy.
More effective lesion formation.

The main weakness of the review is the lack of direct comparative data between the different ventilation strategies, which the authors acknowledge, calling out the need for randomised controlled trials comparing these strategies.

Nevertheless, the review makes a compelling argument for the use of an anaesthetic technique that avoids ventilation variability – and the less variability, the better.

Less is more: Do laryngeal masks reduce atelectasis compared to endotracheal tubes?

Liu and colleagues investigated whether laryngeal mask airway (LMA) use reduces atelectasis formation during general anaesthesia, compared to endotracheal tubes (ETT) – relevant given that ~90% of patients develop some degree of atelectasis after induction.

This was a single-centre, double-blind RCT of 180 patients undergoing non-laparoscopic surgery under 2 hours, with intention-to-treat analysis. They used lung ultrasound (LUS) scoring to assess atelectasis at various timepoints (15 min post-induction, pre-emergence and 30 min after extubation) along with oxygenation. All patients were induced with sufentanil, propofol and rocuronium, and maintained with propofol/remifentanil TIVA. Ventilation was volume controlled with TV 6-8 mL/kg and PEEP 5 cmH2O, I:E 1:1.5, RR 12-20 and FiO2 40%.

Surprisingly the LMA group showed significantly lower LUS scores at all three timepoints, along with better oxygenation and fewer postoperative pulmonary complications.

The authors propose several mechanisms to explain the superiority of LMAs:

Faster Airway Insertion

Shorter apnea time during airway placement (41 vs 95 seconds).
Less time for oxygen absorption in preoxygenated alveoli to cause absorptive atelectasis.
As they note: "Prolonged ventilation pause during this period can easily lead to excessive absorption of oxygen in the alveoli, causing absorptive atelectasis".

Reduced Airway Irritation

Less manipulation of the throat.
Reduced stimulation of airway reflexes.
Lower risk of bronchospasm and secretions.
Less risk of small airway obstruction.
Better preserved mucociliary clearance rates.

Lower Muscle Relaxant Requirements

"After anesthesia induction and administration of muscle relaxants, the weakening of inspiratory muscle tension in patients leads to a relative increase in intra-abdominal pressure. The relaxed diaphragm moves cephalad, reducing the cross-sectional area of the chest, thereby altering the geometry of the thoracic cavity and increasing chest wall pressure, subsequently compressing lung tissue and causing compressive atelectasis."

Reduced Anaesthetic Requirements

Lower doses of sufentanil and rocuronium for induction.
Lower maintenance doses of propofol and remifentanil.
Better preserved respiratory function.

Particularly relevant in this study, "the majority of surgeries in both groups being endoscopic procedures, resulting in minimal demand for anesthetic drugs. Therefore, the increase in the required dose of anesthetic drugs to attenuate cough reflex during endotracheal intubation becomes more significant." Thus the effect could be more about depth of anaesthesia and muscle relaxation than airway choice per se.

The authors note: "Compared to endotracheal intubation, laryngeal masks effectively reduce atelectasis formation and progression in gynecological, urological non-laparoscopic, and orthopedic limb surgeries."

The study is mainly limited by the lack of neuromuscular monitoring and the restriction to relatively healthy patients having shorter (mainly endoscopic!) procedures – arguably the group that atelectasis is least clinically important for!

Nonetheless, the results suggest that when appropriate, using an LMA rather than ETT may reduce atelectasis formation. The authors acknowledge this may not apply to longer procedures, laparoscopic surgery, or higher-risk patients; and naturally the risk-benefit balance of an unprotected airway versus an ETT needs to be considered.

"Rapid insertion and less airway irritation are key factors contributing to the LMA's ability to decrease the formation of absorptive atelectasis."

Mentioned studies:

CAB da Silveira, ACD Rasador, HJS Medeiros et al. Opioid-free anesthesia for minimally invasive abdominal surgery: a systematic review, meta-analysis, and trial sequential analysis. Can J Anaesth. 2024 Nov 5.
Ford P, Cheung AR, Khan MS et al. Anesthetic Techniques for Ablation in Atrial Fibrillation: A Comparative Review. J. Cardiothorac. Vasc. Anesth. 2024 Nov 1; 38 (11): 275427602754-2760.
Liu B, Wang Y, Li L et al. The effects of laryngeal mask versus endotracheal tube on atelectasis after general anesthesia induction assessed by lung ultrasound: A randomized controlled trial. J Clin Anesth. 2024 Nov 1; 98: 111564111564.