Laryngeal Mask Airway for neonatal resuscitation in a developing country: evaluation of an educational intervention. Neonatal LMA: an educational intervention in DRC

Simulation-Based Training in Emergency Obstetric Care in Sub-Saharan and Central Africa: A Scoping Review

Background

Every day approximately 810 women die from complications related to pregnancy and childbirth worldwide. Around two thirds of these deaths happen in sub-Saharan Africa. One of the strategies to decrease these numbers is improving the quality of care by emergency obstetric simulation-based training. The effectiveness of such training programs depends on the program's instructional design.

Objective

This review gives an overview of studies about emergency obstetric simulation-based training and examines the applied instructional design of the training programs in sub-Saharan and Central Africa.

Methods

We searched Medline, Embase and Cochrane Library from inception to May 2021. Peer-reviewed articles on emergency obstetric, postgraduate, simulation-based training in sub-Saharan and Central Africa were included. Outcome measures were categorized based on Kirkpatrick's levels of training evaluation. The instructional design was evaluated by using the ID-SIM questionnaire.

Findings

In total, 47 studies met the inclusion criteria. Evaluation on Kirkpatrick level 1 showed positive reactions in 18 studies. Challenges and recommendations were considered. Results on knowledge, skills, and predictors for these results (Kirkpatrick level 2) were described in 29 studies. Retention as well as decay of knowledge and skills over time were presented. Results at Kirkpatrick level 3 were measured in 12 studies of which seven studies demonstrated improvements of skills on-the-job. Improvements of maternal and neonatal outcomes were described in fifteen studies and three studies reported on cost-estimations for training rollout (Kirkpatrick level 4). Instructional design items were heterogeneously applied and described.

Conclusions

Results of 47 studies indicate evidence that simulation-based training in sub-Saharan and Central Africa can have a positive impact across all four levels of Kirkpatrick's training evaluation model. However, results were not consistent across all studies and the effects vary over time. A detailed description of instructional design features in future publications on simulation-based training will contribute to a deeper understanding of the underlying mechanisms that determine why certain training programs are more effective in improving maternal and neonatal healthcare outcomes than other.

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

BACKGROUND

Effective positive-pressure ventilation is a critical factor in newborn resuscitation. Neonatal endotracheal intubation (ETT) needs considerable training and experience, which poses a human factor challenge. Laryngeal mask airway (LMA) ventilation can be a secure and viable alternative during the initial stages of newborn resuscitation. However, there is limited evidence for its use during chest compression (CC).

METHODS

Seventeen lambs were randomized into LMA or ETT ventilation post cord occlusion induced cardiac arrest. After 5 min of cardiac arrest, resuscitation was initiated as per NRP recommendations. Ventilation, oxygenation, systemic and pulmonary hemodynamic parameters were recorded till the return of spontaneous circulation (ROSC) or 20 min.

RESULTS

Baseline characteristics were similar between the groups. The incidence of ROSC was 75% (6/8) in the LMA group and 56% (5/9) in the ETT group (p = 0.74). The median (IQR) time to achieve ROSC was 6.85 min (6 min-9.1 min) in the LMA group and 7.50 min (5.33 min-18 min) in the ETT group (p = 0.65).

CONCLUSION

LMA ventilation during CC is feasible and non-inferior to ETT in this model.

IMPACT

Laryngeal mask airway (LMA) ventilation with chest compression is feasible and non-inferior to endotracheal tube ventilation in this experimental near-term lamb model of asphyxial cardiac arrest. First translational study to evaluate the use of LMA as an airway device with chest compression. Evidence primer for clinical studies to evaluate and confirm the feasibility and efficacy of LMA ventilation with chest compression are necessary before randomized clinical trials in neonates. LMA use in neonatal cardiopulmonary resusciation (CPR) could have the potential to optimize advanced resuscitation, especially in resource-limited healthcare settings.

Knowledge Outcome of Essential Care for Every Baby Training in Southern Nations, Nationalities, and People's Region, Ethiopia: A Pre- and Post-Test Study

This study was aimed to evaluate the knowledge outcome of ECEB training given to reduce neonatal mortality in Ethiopia. The study was conducted by using data from training given for 98 health professionals. Data were entered into Epi info7 and analyzed by SPSS version 21. Accordingly, the paired sample T-test, the independent sample t-test, and one way ANOVA were calculated at P-value <.05. Likewise, the mean knowledge score of the trainees increased from 59.10 (SD ± 13.180) before the training to 73.73 (SD ± 14.173) after the training. The increment was statistically significant (t (97) = 11.684, CI = 12.147-17.118, P < 0.001). The mean knowledge score was significantly varied between female and male trainees at pre-test t (96) = 2.424, P = .017 and post-test t (96) = 2.944, P = .004. Similarly, it was significantly varied between trainees from hospitals and Health centers at post-test t (96) = 2.403, P = .018. To sum up, the overall knowledge outcome of trainees significantly improved after the training. However, regarding knowledge outcome in relation to different variables, there was a significant mean knowledge score difference by sex both at pre- and post-test. Concerning the knowledge outcome in relation to facility type of the trainees, knowledge outcome significantly increased only those who came from hospitals at post-test. Therefore, to further enhance female trainees and those who come from Health Centers, a separate training session with extra support should be arranged by programmers.

Laryngeal mask airway use during neonatal resuscitation: a survey of practice across newborn intensive care units and neonatal retrieval services in Australian New Zealand Neonatal Network

This is an Australia New Zealand Neonatal Network (ANZNN) wide survey to identify current practice and guide future practice improvement for the use of laryngeal mask airway (LMA) during neonatal resuscitation. An online questionnaire containing 13 questions was sent out to all tertiary neonatal centres (n = 29 units) and neonatal transport units (n = 4) within ANZNN. The non-tertiary (level-II) centres were not included. Response from a senior neonatologist at each centre was received and evaluated. Twenty-two services (67%) had LMA available; of that only, 40% felt the competency of staff to be adequate; and 59% had routine training in LMA use. During neonatal resuscitation, 68% units reported using LMA if endotracheal intubation was unsuccessful after two or more failed intubation attempts and only 18% used it before intubation if face mask ventilation was inadequate. This survey highlighted variations in practice across the tertiary neonatal centres in ANZNN network. One-third of the units lack LMA availability and the units with LMA, face concerns of underutilisation and lack of skills for its use.

How do different brands of size 1 laryngeal mask airway compare with face mask ventilation in a dedicated laryngeal mask airway teaching manikin?

BACKGROUND

International neonatal resuscitation guidelines recommend the use of laryngeal mask airway (LMA) with newborn infants (≥34 weeks' gestation or >2 kg weight) when bag-mask ventilation (BMV) or tracheal intubation is unsuccessful. Previous publications do not allow broad LMA device comparison.

OBJECTIVE

To compare delivered ventilation of seven brands of size 1 LMA devices with two brands of face mask using self-inflating bag (SIB).

DESIGN

40 experienced neonatal staff provided inflation cycles using SIB with positive end expiratory pressure (PEEP) (5 cmH₂O) to a specialised newborn/infant training manikin randomised for each LMA and face mask. All subjects received prior education in LMA insertion and BMV.

RESULTS

12 415 recorded inflations for LMAs and face masks were analysed. Leak detected was lowest with i-gel brand, with a mean of 5.7% compared with face mask (triangular 42.7, round 35.7) and other LMAs (45.5-65.4) (p<0.001). Peak inspiratory pressure was higher with i-gel, with a mean of 28.9 cmH₂O compared with face mask (triangular 22.8, round 25.8) and other LMAs (14.3-22.0) (p<0.001). PEEP was higher with i-gel, with a mean of 5.1 cmH₂O compared with face mask (triangular 3.0, round 3.6) and other LMAs (0.6-2.6) (p<0.001). In contrast to other LMAs examined, i-gel had no insertion failures and all users found i-gel easy to use.

CONCLUSION

This study has shown dramatic performance differences in delivered ventilation, mask leak and ease of use among seven different brands of LMA tested in a manikin model. This coupled with no partial or complete insertion failures and ease of use suggests i-gel LMA may have an expanded role with newborn resuscitation as a primary resuscitation device.

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.

Pilot manikin study showed that a supraglottic airway device improved simulated neonatal ventilation in a low-resource setting

AIM

We compared the performance of personnel in a low-resource setting when they used the I-gel cuffless neonatal laryngeal mask or a face mask on a neonatal airway management manikin.

METHODS

At Mulago Hospital, Uganda, 25 doctors, nurses and midwives involved in neonatal resuscitation were given brief training with the I-gel and face mask. Then, every participant was observed positioning both devices on three consecutive occasions. The success rate and insertion times leading to effective positive pressure ventilation (PPV) were recorded. Participants rated the perceived efficiency of the devices using a five-point Likert scale.

RESULTS

The I-gel achieved a 100% success rate on all three occasions, but the face mask was significantly less effective in achieving effective PPV and the failure rates at the first, second and third attempts were 28%, 8% and 20%, respectively. The perceived efficiency of the devices was significantly superior for the I-gel (4.7 ± 0.4) than the face mask (3.3 ± 0.8).

CONCLUSION

The I-gel was more effective than the face mask in establishing PPV in the manikin, and user satisfaction was higher. These encouraging manikin data could be a stepping stone for clinical research on the use of the I-gel for neonatal resuscitation in low-resource settings.

Newborn Resuscitation Training in Resource-Limited Settings: A Systematic Literature Review

CONTEXT

Birth asphyxia contributes substantially to neonatal mortality in low- and middle-income countries (LMICs). The effects of training birth attendants in neonatal resuscitation (NR) on mortality are limited by falloff of skills and knowledge over time and transference of learned skills into clinical practice.

OBJECTIVE

This review examined acquisition and retention of NR knowledge and skills by birth attendants in LMICs and the effectiveness of interventions to improve them.

DATA SOURCES

Medline, Cochrane, Embase, CINAHL, Bireme, and African Index Medicus databases were searched. We reviewed Web pages and reports from non-peer-reviewed (or "gray") literature sources addressing NR training in LMICs.

STUDY SELECTION

Articles on acquisition and retention of NR knowledge and skills, and interventions to improve them, were limited to LMICs.

RESULTS

The initial search identified 767 articles, of which 45 met all inclusion criteria. Of these, 31 articles analyzed acquisition of knowledge and skills, and 19 analyzed retention. Most studies found high acquisition rates, although birth attendants struggled to learn bag-mask ventilation. Although significant falloff of knowledge and skills occurred after training, refresher training seemed to improve retention. Results of the gray literature analysis suggest that formal, structured practice sessions improve retention.

LIMITATIONS

This review did not analyze training's direct impact on mortality.

CONCLUSIONS

Knowledge and skills falloff is a significant barrier to the success of NR training programs and possibly to reducing newborn mortality in LMICs. Refresher training and structured practice show significant promise. Additional research is needed to implement and assess retention improvement strategies in classroom and clinical settings.

Impact of a Developmental Care Training Course on the Knowledge and Satisfaction of Health Care Professionals in Neonatal Units: A Multicenter Study

BACKGROUND

The impact of health-related continuing education courses on knowledge acquisition and clinical practice is infrequently evaluated, despite higher numbers of people enrolling in them. The majority of health care professionals working in neonatal intensive care units (NICUs) have received no training in developmental care (DC). The purpose of this study was to determine whether participation in a theoretical-practical course on DC had an effect on the degree of knowledge possessed by professionals in general terms and with respect to neonatal intensive care. The relationship between course satisfaction and knowledge acquisition was also studied.

METHODS

This was an observational multicenter study conducted in 20 neonatal units in Madrid. A pre- and post-course questionnaire evaluated both knowledge and satisfaction levels regarding the course on DC and the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). We carried out a multivariate linear regression analysis to determine whether there was a correlation between knowledge gained and satisfaction level.

RESULTS

A total of 566 professionals participated, with a 99% pre-course and a 90% post-course response rate. The mean rate of correct pre-course answers was 65%, while the mean rate of post-course correct answers was 81% (p < 0.001). Results were similar at all levels of neonatal care (Level I: 64% vs 80%; Level II: 64% vs. 83%; and

LEVEL III

65% vs. 81%). Scores on a scale of satisfaction from 1 to 5 were high (averages of above 4 for all lectures and workshops). Pre-course knowledge scores, but not satisfaction, significantly influenced post-course knowledge (β 0.499; p < 0.01).

CONCLUSION

Previous DC knowledge among Madrid health care professionals was similar, regardless of the level of neonatal care. Course attendance significantly improved the rate of correct answers. Although course satisfaction was high, there did not seem to be a correlation between knowledge gained and satisfaction.

Supreme Laryngeal Mask Airway versus Face Mask during Neonatal Resuscitation: A Randomized Controlled Trial

OBJECTIVE

To assess the effectiveness of supreme laryngeal mask airway (SLMA) over face mask ventilation for preventing need for endotracheal intubation at birth.

STUDY DESIGN

We report a prospective, randomized, parallel 1:1, unblinded, controlled trial. After a short-term educational intervention on SLMA use, infants ≥34-week gestation and/or expected birth weight ≥1500 g requiring positive pressure ventilation (PPV) at birth were randomized to resuscitation by SLMA or face mask. The primary outcome was the success rate of the resuscitation devices (SLMA or face mask) defined as the achievement of an effective PPV preventing the need for endotracheal intubation.

RESULTS

We enrolled 142 patients (71 in SLMA and 71 in face mask group, respectively). Successful resuscitation rate was significantly higher with the SLMA compared with face mask ventilation (91.5% vs 78.9%; P = .03). Apgar score at 5 minutes was significantly higher in SLMA than in face mask group (P = .02). Neonatal intensive care unit admission rate was significantly lower in SLMA than in face mask group (P = .02). No complications related to the procedure occurred.

CONCLUSIONS

In newborns with gestational age ≥34 weeks and/or expected birth weight ≥1500 g needing PPV at birth, the SLMA is more effective than face mask to prevent endotracheal intubation. The SLMA is effective in clinical practice after a short-term educational intervention.

TRIAL REGISTRATION

Registered with ClinicalTrials.gov: NCT01963936.

Implementation and evaluation of the Helping Babies Breathe curriculum in three resource limited settings: does Helping Babies Breathe save lives? A study protocol

BACKGROUND

Neonatal deaths account for over 40% of all under-5 year deaths; their reduction is increasingly critical for achieving Millennium Development Goal 4. An estimated 3 million newborns die annually during their first month of life; half of these deaths occur during delivery or within 24 hours. Every year, 6 million babies require help to breathe immediately after birth. Resuscitation training to help babies breathe and prevent/manage birth asphyxia is not routine in low-middle income facility settings. Helping Babies Breathe (HBB), a simulation-training program for babies wherever they are born, was developed for use in low-middle income countries. We evaluated whether HBB training of facility birth attendants reduces perinatal mortality in the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Global Network research sites.

METHODS/DESIGN

We hypothesize that a two-year prospective pre-post study to evaluate the impact of a facility-based training package, including HBB and essential newborn care, will reduce all perinatal mortality (fresh stillbirth or neonatal death prior to 7 days) among the Global Network's Maternal Neonatal Health Registry births ≥1500 grams in the study clusters served by the facilities. We will also evaluate the effectiveness of the HBB training program changing on facility-based perinatal mortality and resuscitation practices. Seventy-one health facilities serving 52 geographically-defined study clusters in Belgaum and Nagpur, India, and Eldoret, Kenya, and 30,000 women will be included. Primary outcome data will be collected by staff not involved in the HBB intervention. Additional data on resuscitations, resuscitation debriefings, death audits, quality monitoring and improvement will be collected. HBB training will include training of MTs, facility level birth attendants, and quality monitoring and improvement activities.

DISCUSSION

Our study will evaluate the effect of a HBB/ENC training and quality monitoring and improvement package on perinatal mortality using a large multicenter design and approach in 71 resource-limited health facilities, leveraging an existing birth registry to provide neonatal outcomes through day 7. The study will provide the evidence base, lessons learned, and best practices that will be essential to guiding future policy and investment in neonatal resuscitation.

TRIAL REGISTRATION

Trial registration ClinicalTrials.gov Identifier: NCT01681017.

New concepts in neonatal resuscitation

PURPOSE OF REVIEW

There has been a substantial increase in the number of studies of neonatal resuscitation and it is timely to review the accumulating evidence.

RECENT FINDINGS

There have been major changes in the way that newly born infants are managed in the delivery room. Colour is no longer recommended as a useful indicator of oxygenation or effectiveness of resuscitation. Pulse oximetry provides rapid, continuous and accurate information on both oxygenation and heart rate. Resuscitation of term infants should begin with air, with the provision of blended oxygen to maintain oxygen saturations similar to those of term infants requiring no resuscitation. Positive end-expiratory pressure during initial ventilation aids lung aeration and establishment of functional residual capacity. Respiratory function monitoring allows operators to identify factors adversely affecting ventilation, including leak around the face mask and airway obstruction. Clamping of the umbilical cord should be delayed for at least 1 min for infants not requiring resuscitation.

SUMMARY

The International Liaison Committee on Resuscitation guidelines on the management of newborn infants were updated in 2010 and incorporate much of the newly available evidence. The use of intensive care techniques in the delivery room is promising but requires further evaluation. Monitoring techniques and interventions need to be adapted for use in developing countries.