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Author(s): Pooja Bihani [1]; Shivanand [2]; Rishabh Jaju [3]; Naveen Paliwal (corresponding author) [1]; Sarita Janweja [1]; Ankit Vyas [4] INTRODUCTION Effective airway management is crucial in paediatric anaesthesia, where [...], Background and Aims: The second-generation supraglottic airway device is conventionally inserted blindly, which might result in suboptimal placement. Limited literature exists on under-vision insertion techniques, particularly in paediatric patients. The primary objective of this study was to compare the oropharyngeal leak pressure (OPLP) between the blind insertion of the LMA Blockbuster[sup.®] and the Miller laryngoscope-guided insertion in children. Secondary outcomes included the number of insertion attempts, haemodynamic disturbances, insertion time and airway complications. Methods: This randomised controlled trial study enroled 100 patients aged 1-4 years undergoing elective surgery. Patients were randomised into blind insertion (Group A) or Miller laryngoscope-guided insertion (Group B) of the LMA Blockbuster[sup.®]. The primary outcome measure was OPLP. Insertion time, haemodynamic changes and postoperative complications were also assessed. The Chi-square, Fisher's exact and t-test were applied appropriately, with the significance level set at P < 0.05. Results: Significantly higher mean OPLP was observed in Group B compared to Group A - 27.9 [standard deviation (SD): 1.58] cmH[sub.2]O versus 25.94 (SD: 0.63) cmH[sub.2]O [mean difference (MD): 1.96 (95% confidence interval {CI}: 1.48, 2.44; P < 0.001)]. Mean insertion time was longer in Group B, that is, 11.9 (SD: 1.91) s versus 8.7 (SD: 0.6) s [MD: 3.2 s; (95% CI: 2.63, 3.76; P < 0.001)]; however, the difference was not clinically relevant. First-attempt insertion, haemodynamic stability and postoperative complications were comparable (P > 0.05). Conclusion: Miller laryngoscope-guided under-vision insertion of LMA Blockbuster[sup.®] improves alignment with epiglottic structures compared to blind insertion. Keywords: Blind insertion, haemodynamic, laryngeal mask airway, laryngoscope, LMA Blockbuster, paediatric anaesthesia, ventilation