Use of laryngeal masks in the resuscitation of a neonate with difficult airway

Introduction of laryngeal mask airway in Japan, and its rescue use for newborns

BACKGROUND

In neonatal resuscitation, laryngeal mask airway (LMA) is recommended when both face mask ventilation and endotracheal intubation fail. Experience of LMA among obstetricians, nurses and midwives in Japan, however, is limited. The aims of the present study were to (i) offer an LMA training course to professionals dealing with low-risk pregnancies at institutions across Japan; and (ii) assess the subsequent use and value of LMA at the participating institutions.

METHODS

Between August 2016 and March 2017, a total of 18 training courses for 60 min were provided for around 350 medical personnel from 51 institutes. LMA use over the subsequent 12 months was assessed via a postal questionnaire.

RESULTS

After training, a total of 38 institutes introduced LMA. Of 13 254 live births, seven cases of rescue use LMA in "cannot ventilate, cannot intubate" situations were reported. None of these seven newborns had any malformation of the upper airway. LMA insertion resulted in adequate ventilation in all seven cases.

CONCLUSION

LMA can be a life-saving tool in neonatal resuscitation. All medical institutions dealing with low-risk pregnancies in Japan should be equipped with this device.

Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation

BACKGROUND

Providing effective positive pressure ventilation is considered to be the single most important component of successful neonatal resuscitation. Ventilation is frequently initiated manually with bag and face mask (BMV) followed by endotracheal intubation if respiratory depression continues. These techniques may be difficult to perform successfully resulting in prolonged resuscitation or neonatal asphyxia. The laryngeal mask airway (LMA) may achieve initial ventilation and successful resuscitation faster than a bag-mask device or endotracheal intubation.

OBJECTIVES

Among newborns requiring positive pressure ventilation for cardio-pulmonary resuscitation, is LMA more effective than BMV or endotracheal intubation for successful resuscitation? When BMV is either insufficient or ineffective, is effective positive pressure ventilation and successful resuscitation achieved faster with the LMA compared to endotracheal intubation?

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1), MEDLINE via PubMed (1966 to 15 February 2017), Embase (1980 to 15 February 2017), and CINAHL (1982 to 15 February 2017). We also searched clinical trials registers, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that compared LMA for neonatal resuscitation with either BMV or endotracheal intubation and reported on any outcomes related to neonatal resuscitation specified in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated studies for risk of bias assessments, and extracted data using Cochrane Neonatal criteria. Categorical treatment effects were described as relative risks and continuous treatment effects were described as the mean difference, with 95% confidence intervals (95% CI) of estimates.

MAIN RESULTS

We included seven trials that involved a total of 794 infants. Five studies compared LMA with BMV and three studies compared LMA with endotracheal intubation. We added six new studies for this update (754 infants).LMA was associated with less need for endotracheal intubation than BMV (typical risk ratio (RR) 0.24, 95% CI 0.12 to 0.47 and typical risk difference (RD) -0.14, 95% CI -0.14 to -0.06; 5 studies, 661 infants; moderate-quality evidence) and shorter ventilation time (mean difference (MD) -18.90 seconds, 95% CI -24.35 to -13.44; 4 studies, 610 infants). Babies resuscitated with LMA were less likely to require admission to neonatal intensive care unit (NICU) (typical RR 0.60, 95% CI 0.40 to 0.90 and typical RD -0.18, 95% CI -0.31 to -0.04; 2 studies,191 infants; moderate-quality evidence). There was no difference in deaths or hypoxic ischaemic encephalopathy (HIE) events.Compared to endotracheal intubation, there were no clinically significant differences in insertion time or failure to correctly insert the device (typical RR 0.95, 95% CI 0.17 to 5.42; 3 studies, 158 infants; very low-quality evidence). There was no difference in deaths or HIE events.

AUTHORS' CONCLUSIONS

LMA can achieve effective ventilation during neonatal resuscitation in a time frame consistent with current neonatal resuscitation guidelines. Compared to BMV, LMA is more effective in terms of shorter resuscitation and ventilation times, and less need for endotracheal intubation (low- to moderate-quality evidence). However, in trials comparing LMA with BMV, over 80% of infants in both trial arms responded to the allocated intervention. In studies that allowed LMA rescue of infants failing with BMV, it was possible to avoid intubation in the majority. It is important that the clinical community resorts to the use of LMA more proactively to provide effective ventilation when newborn is not responding to BMV before attempting intubation or initiating chest compressions.LMA was found to offer comparable efficacy to endotracheal intubation (very low- to low-quality evidence). It therefore offers an alternate airway device when attempts at inserting endotracheal intubation are unsuccessful during resuscitation.Most studies enrolled infants with birth weight over 1500 g or 34 or more weeks' gestation. As such, there is lack of evidence to support LMA use in more premature infants.

The Laryngeal Mask Airway and Its Use in Neonatal Resuscitation: A Critical Review of Where We Are in 2017/2018

Studies using videotape recordings and respiratory function monitoring have shown that both face mask (FM) application and endotracheal tube (ETT) placement represent a challenge for resuscitators. Hence, there is a strong need for devices that can largely be used independently of individual operator training levels, in order to ensure more reliable support in time-critical situations, such as neonatal resuscitation. The laryngeal mask airway device (LMA) has evolved as a potentially very valuable tool. We conducted a systematic review of studies evaluating the use of the LMA in neonatal resuscitation. An electronic literature search of large medical databases was performed to identify relevant publications on the use of an LMA during neonatal delivery room (DR) resuscitation. Following a rigorous systematic review, we identified a total of 7 randomized controlled trials with results indicating that initial respiratory management of newborn infants with an LMA is feasible for a defined subgroup of infants, but the evidence is still insufficient to recommend the LMA instead of FM ventilation in the DR. There is, in particular, a dearth of evidence of the use of LMA in neonates born before 34 weeks' gestational age or weighing <1,500 g at birth. There were no reports on significant complications following the use of LMA; however, evidence is still limited regarding short- and long-term outcomes. We conclude that the limited currently available evidence suggests that the use of the LMA is a feasible and safe alternative to mask ventilation of late preterm and term infants in the DR. The potential use of LMA resuscitation, in particular for low-gestation and low-birth-weight infants, needs further study.

Alternative ventilation strategies: laryngeal masks

The appropriate role for laryngeal masks during delivery room resuscitation has not been established. The authors systematically reviewed the literature to answer three clinical questions: (1) In newborns requiring positive-pressure ventilation for resuscitation, would a laryngeal mask achieve safe and effective ventilation faster than facemask ventilation? (2) In newborns unable to be ventilated effectively with a facemask during resuscitation, would a laryngeal mask achieve effective ventilation faster than endotracheal intubation? (3) In newborns requiring resuscitation, would a laryngeal mask achieve effective ventilation when facemask ventilation and endotracheal intubation have been unsuccessful?

Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation

BACKGROUND

Providing effective positive pressure ventilation is the single most important component of successful neonatal resuscitation. Ventilation is frequently initiated with a manual resuscitation bag and face-mask (BMV) followed by endotracheal intubation (ETT) if depression continues. These techniques may be difficult to perform successfully resulting in prolonged resuscitation or severe neonatal depression. The laryngeal mask airway (LMA) may achieve initial ventilation and successful resuscitation faster than a bag-mask device or endotracheal intubation.

OBJECTIVES

Among newborns requiring positive pressure ventilation for resuscitation, is effective ventilation and successful resuscitation achieved faster with the LMA compared with either BMV or ETT?

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), MEDLINE (1966-November 2004), Pre-MEDLINE (November 15, 2004), CINAHL 1982-November 2004), reference lists of published trials, and Society for Pediatric Research abstracts were searched. Experts were contacted for additional references.

SELECTION CRITERIA

Randomised and quasi-randomised trials

DATA COLLECTION AND ANALYSIS

Two reviewers independently evaluated studies, assessed methodologic quality, and extracted data using the Cochrane Neonatal Review Group criteria. Categorical treatment effects were described as relative risks and risk differences and continuous treatment effects were described as the mean difference. There were insufficient data to perform pooled analyses.

MAIN RESULTS

No eligible studies compared the LMA with BMV. One small randomised controlled trial comparing the LMA with ETT when BMV had been unsuccessful was included. There was no statistically significant difference between the LMA and ETT with the exception of a clinically insignificant difference in time to complete insertion of the device favouring the ETT.

AUTHORS' CONCLUSIONS

The LMA can achieve effective ventilation during neonatal resuscitation in a time-frame consistent with current guidelines. There is no evidence to evaluate the relative efficacy and safety of the LMA compared with BMV as the primary airway device. A single, small randomised controlled trial found no clinically significant difference between the LMA and ETT when BMV was unsuccessful. Case series and case reports suggest that the LMA can provide an effective rescue airway during resuscitation if both BMV and ETT have been unsuccessful. A well-designed randomised controlled trial comparing the LMA with BMV during neonatal resuscitation is warranted.