Laryngeal mask ventilation with chest compression during neonatal resuscitation: randomized, non-inferiority trial in lambs

Laryngeal Mask Airway in Neonatal Resuscitation: A Survey of the Union of European Neonatal and Perinatal Societies

INTRODUCTION

Laryngeal mask airway (LMA) use in neonatal resuscitation is limited despite existing evidence and recommendations. This survey investigated the knowledge and experience of healthcare providers on the use of the LMA and explored barriers and solutions for implementation.

METHODS

This online, cross-sectional survey on LMA in neonatal resuscitation involved healthcare professionals of the Union of European Neonatal and Perinatal Societies (UENPS).

RESULTS

A total of 858 healthcare professionals from 42 countries participated in the survey. Only 6% took part in an LMA-specific course. Some delivery rooms were not equipped with LMA (26.1%). LMA was mainly considered after the failure of a face mask (FM) or endotracheal tube (ET), while the first choice was limited to neonates with upper airway malformations. LMA and FM were considered easier to position but less effective than ET, while LMA was considered less invasive than ET but more invasive than FM. Participants felt less competent and experienced with LMA than FM and ET. The lack of confidence in LMA was perceived as the main barrier to its implementation in neonatal resuscitation. More training, supervision, and device availability in delivery wards were suggested as possible actions to overcome those barriers.

CONCLUSION

Our survey confirms previous findings on limited knowledge, experience, and confidence with LMA, which is usually considered an option after the failure of FM/ET. Our findings highlight the need for increasing the availability of LMA in delivery wards. Moreover, increasing LMA training and having an LMA expert supervisor during clinical practice may improve the implementation of LMA use in neonatal clinical practice.

Updates in neonatal resuscitation: routine use of laryngeal masks as an alternative to face masks

Although positive-pressure ventilation (PPV) has traditionally been performed using a face mask in neonatal resuscitation, face mask ventilation for delivering PPV has a high failure rate due to mask leaks, airway obstruction, or gastric inflation. Furthermore, face mask ventilation is compromised during chest compressions. Endotracheal intubation in neonates requires a high skill level, with a first-attempt success rate of <50%. Laryngeal masks can transfer positive pressure more effectively even during chest compressions, resulting in a lower PPV failure rate compared to that of face masks in neonatal resuscitation. In addition, inserting a laryngeal mask is easier and more accessible than endotracheal intubation, and mortality rates do not differ between the 2 methods. Therefore, in neonatal resuscitation, laryngeal masks are recommended in infants with gestational age >34 weeks and/or with a birth weight >2 kg, in cases of unsuccessful face mask ventilation (as a primary airway device) or endotracheal intubation (as a secondary airway device, alternative airway). In other words, laryngeal masks are recommended when endotracheal intubation fails as well as when PPV cannot be achieved. Although laryngeal masks are commonly used in anesthetized pediatric patients, they are infrequently used in neonatal resuscitation due to limited experience, a preference for endotracheal tubes, or a lack of awareness among the healthcare providers. Thus, healthcare providers must be aware of the usefulness of laryngeal masks in depressed neonates requiring PPV or endotracheal intubation, which can promptly resuscitate these infants and improve their outcomes, resulting in decreased morbidity and mortality rates.

Supraglottic airway devices: a powerful strategy in airway management

The escalating airway management demands of cancer patients have prompted us to continually curate airway devices, with supraglottic airway devices (SADs) playing a significant role in this regard. SADs serve as instrumental tools for maintaining an open upper airway. Since the inception of the earliest SADs in the early 1980s, an array of advanced and enhanced second-generation devices have been employed in clinical settings. These upgraded SADs integrate specific features designed to enhance positive-pressure ventilation and mitigate the risk of aspiration. Nowadays, they are extensively used in general anesthesia procedures and play a critical role in difficult airway management, pre-hospital care, and emergency medicine. In certain situations, SADs may be deemed a superior alternative to endotracheal tube (ETT) and can be employed in a broader spectrum of surgical and non-surgical cases. This review provides an overview of the current evidence, a summary of classifications, relevant application scenarios, and areas for improvement in the development or clinical application of future SADs.

Laryngeal mask airway versus face mask ventilation or intubation for neonatal resuscitation in low-and-middle-income countries: a systematic review and meta-analysis

OBJECTIVE

To assess whether laryngeal mask airway (LMA) as compared with face mask (FM) or endotracheal intubation (ETT) is more effective in delivering positive pressure ventilation (PPV) during neonatal resuscitation in low-and-middle income countries (LMICs).

STUDY DESIGN

We followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and searched Medline (PubMed interphase), Cumulative Index of Nursing and Allied Health Literature, Embase and Cochrane Registry between January 1990 and April 2022 for the studies that examined the effect of LMA in delivering PPV compared with the FM or ETT in infants during neonatal resuscitation. We included the studies conducted in LMIC only. We assessed the quality of all the included studies using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) recommendations.

RESULTS

Our search resulted in eight randomised studies Six studies compared LMA with FM and three studies compared LMA with ETT. When used as the primary device for providing PPV, the LMA as compared with FM resulted in a significant lower failure rate (relative risk (RR) 0.23, 95% CI 0.13 to 0.43) with moderate certainty of evidence (CoE) and lesser need for intubation (RR 0.21, 95% CI 0.07 to 0.58) with low CoE. There was no difference in the incidence of encephalopathy, neonatal admission, need for advanced resuscitations or death. No differences were observed between LMA and ETT. Studies comparing LMA to ETT were limited for any conceivable conclusion.

CONCLUSION

LMA is more effective than FM in delivering PPV with less failure rates and reduced need for intubation during neonatal resuscitation in term infants and in LMIC without any difference in the incidence of encephalopathy or death. Studies comparing LMA to ETT are scarce with important methodological limitations.

PROSPERO REGISTRATION NUMBER

CRD42021283478.

Effect of Intermediate Airway Management on Ventilation Parameters in Simulated Pediatric Out-of-Hospital Cardiac Arrest: Protocol for a Multicenter, Randomized, Crossover Trial

Most pediatric out-of-hospital cardiac arrests (OHCAs) are caused by hypoxia, which is generally consecutive to respiratory failure. To restore oxygenation, prehospital providers usually first use basic airway management techniques, i.e., bag-valve-mask (BVM) devices. These devices present several drawbacks, most of which could be avoided using supraglottic airway devices. These intermediate airway management (IAM) devices also present significant advantages over tracheal intubation: they are associated with higher success and lower complication rates in the prehospital setting. There are, however, few data regarding the effect of early IAM in pediatric OHCA. This paper details the protocol of a trial designed to evaluate the impact of this airway management strategy on ventilation parameters through a simulated, multicenter, randomized, crossover trial. The hypothesis underlying this study protocol is that early IAM without prior BVM ventilations could improve the ventilation parameters in comparison with the standard approach, which consists in BVM ventilations only.

Laryngeal Masks in Neonatal Resuscitation-A Narrative Review of Updates 2022

Positive pressure ventilation (PPV) is crucial to neonatal cardiopulmonary resuscitation because respiratory failure precedes cardiac failure in newborns affected by perinatal asphyxia. Prolonged ineffective PPV could lead to a need for advanced resuscitation such as intubation, chest compression, and epinephrine. Every 30 s delay in initiation of PPV increased the risk of death or morbidity by 16%. The most effective interface for providing PPV in the early phases of resuscitation is still unclear. Laryngeal masks (LMs) are supraglottic airway devices that provide less invasive and relatively stable airway access without the need for laryngoscopy which have been studied as an alternative to face masks and endotracheal tubes in the initial stages of neonatal resuscitation. A meta-analysis found that LM is a safe and more effective alternative to face mask ventilation in neonatal resuscitation. LM is recommended as an alternative secondary airway device for the resuscitation of infants > 34 weeks by the International Liaison Committee on Resuscitation. It is adopted by various national neonatal resuscitation guidelines across the globe. Recent good-quality randomized trials have enhanced our understanding of the utility of laryngeal masks in low-resource settings. Nevertheless, LM is underutilized due to its variable availability in delivery rooms, providers’ limited experience, insufficient training, preference for endotracheal tube, and lack of awareness.