JOURNAL TRANSCRIPT

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Review Neonatology 2018;113:152–161 DOI: 10.1159/000481979

Received: June 6, 2017 Accepted after revision: October 5, 2017 Published online: December 13, 2017

The Laryngeal Mask Airway and Its Use in Neonatal Resuscitation: A Critical Review of Where We Are in 2017/2018 Satvik Chaitanya Bansal a Stefano Caoci c Eugene Dempsey e, f Daniele Trevisanuto d Charles Christoph Roehr a, b   

 

 

 

 

a Newborn

Services, John Radcliffe Hospital, Oxford University Hospitals, NHS Trust, Headley Way, and b Department of Paediatrics, University of Oxford, Oxford, UK; c Division of Neonatology, Policlinico Umberto I, Sapienza University of Rome, Rome, and d Department of Women’s and Children’s Health, Padua University, Azienda Ospediliera di Padova, Padua,Italy; e Department of Paediatrics and Child Health and f Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland  

 

 

 

Keywords Laryngeal mask airway · Intubation · Newborn · Resuscitation · Stabilization

Abstract 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 in-

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fants, 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 34 weeks’ gestational age [GA]), full-term newborns, and/or newborns with a birth weight (BW) >2,000 g when FM ventilation is unsuccessful, and also recommend it when intubation is not feasible [2, 3]. Over the years, a possible role of LMA has been described in various clinical settings such as meconium aspiration, the administration of emergency drugs and surfactant, and during chest compressions and neonatal transport. Consequently, it has been touted that its use could be especially crucial in settings where a lack of operator skill may prevent adequate ventilatory assistance [16]. Unfortunately, most of the evidence has been derived only from case reports and case series. In this article, we will review the available literature on the use of the LMA in newborns, providing an overview for readers. We aim to explore the various indications of the LMA and point out any gaps in knowledge, in order to generate a direction for future studies.

Laryngeal Mask Airway for Newborn Infants

Neonatology 2018;113:152–161 DOI: 10.1159/000481979

Types of LMA

Several modifications have been made to the original design of the LMA in order to improve its effectiveness and ease of use, while limiting the potential complications. Currently, there are various LMAs available for use in newborns (Fig. 1): 1. LMA ClassicTM, LMA ProSealTM, and LMA SupremeTM (LMA North America Inc., San Diego, CA, USA), 2. i-gelTM supraglottic airway (Intersurgical, Liverpool, NY, USA), 3. Ambu® AuraOnceTM (Ambu A/S, Ballerup, Denmark), 4. Air-QTM disposable laryngeal mask airway (Mercury Medical, Clearwater, FL, USA), 5. ShileyTM LMA (Medtronic, USA). The LMA Classic is the original reusable design. LMA ProSeal has modified features to form a better seal with the periglottic tissues, allowing higher seal pressures to be safely achieved with similar ease of insertion compared to LMA Classic [17]. It also has a gastric vent for stomach air removal. LMA Supreme is a disposable polyvinyl chloride (PVC) LMA with an esophageal drain tube and a firm, curved, and anatomically shaped airway tube designed to achieve easier insertion without any introducer tool or placement by using fingers. The Ambu AuraOnce is designed with a rigid curve in the main tube, which supposedly better replicates the hu153

b

e

f

c

d

g

Fig. 1. Various laryngeal mask airway (LMA) devices. a LMA ClassicTM. b LMA SupremeTM. c LMA ProSealTM. d i-gelTM. e Ambu® AuraOnceTM. f Air-QTM. g ShileyTM.

man anatomical airway compared to the classic model. The Air -Q has a shorter and curved shaft, with a claimed advantage that it can be removed after tracheal intubation. The i-gel supraglottic airway is made from thermoplastic elastomer and has a noninflating soft-gel cuff, with the aim of reducing soft-tissue trauma. The Shiley LMA has greater tensile strength and lower flexibility, aiming to make insertion easier and decreasing the chance of occlusion. All neonatal LMAs are available as “size 1” and are indicated for neonates with a BW of ≤5 kg, with the exception of the Air-Q disposable LMA, available as “size 0.5” but with an indication for infants with a BW 1,500 g; Apgar score 34 weeks; BW >2,000 g

LMA (n = 205) vs. FM (n = 164)

Apgar scores; LMA insertion time; rate of successful insertion with 1st attempt; total number of attempts required; response time; need for tracheal intubation

Trevisanuto et al. (2015) [30]

GA >34 weeks; BW >1,500 g

LMA Supreme (n = 71) vs. FM (n = 71)

Success of resuscitation device; 5-min Apgar score; time to the first breath; time to the first cry; death or hypoxic ischemic encephalopathy; complications; admission to NICU or normal nursery

Yang et al. (2016) [31]

GA ≥ 34 weeks or BW ≥2.0 kg with HR 34 weeks; expected BW >2,000 g, need for PPV at birth (apnea and/or gasping and/or HR 34 weeks’ GA and a BW >2,000 g, and that further RCTs were needed to demonstrate the short- and long-term clinical benefits of LMAs. In our review, 7 RCTs (Table 2) have been identified, involving a total of 744 infants, comparing LMA with either ETT or FM ventilation [26–32]. In 4 RCTs, the comparison was between LMA and FM ventilation. Singh et al. [28] randomized (although there is not precise information regarding the randomization process) 50 neonates of >35 weeks’ GA to either LMA or FM ventilation in the DR. The LMA group showed a higher rate success of ventilation (96 vs. 88%) and a shorter “pink-up time” (33.33 vs. 44.52 s). Both devices resulted in similar rates of endotracheal intubation and Apgar scores. Zhu et al. [27] randomized 369 newborn infants (>34 weeks’ GA or weighing >2,000 g) to receive respiratory support at birth with either an LMA or an SIB plus an FM. LMAs were successfully inserted with the first attempt in 98.5%, with a mean insertion time of

Laryngeal Mask Airway for Newborn Infants

Neonatology 2018;113:152–161 DOI: 10.1159/000481979

ing an ETT following either a CS or a vaginal delivery. Overall, the newborns resuscitated with the LMA had better Apgar scores and required less respiratory support after delivery, suggesting, once again, that LMA may have some role in reducing the rate of intubation. However, in their study, the decision to use an LMA or ETT was left to the resuscitator’s discretion without randomization. In 2010, in a 5-year observational study, the same authors reported that resuscitation of late preterm infants (34–37 weeks’ GA) by using an LMA was associated with lower NICU admission rates and a shorter length of stay than mask-ventilation or endotracheal intubation [24]. However, the possibility of selection bias cannot be ruled out as the choice of PPV was at the clinician’s discretion, and so may have resulted in sicker infants being resuscitated with either FM or ETT.

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7.8 s (±2.2). The LMA group had significantly higher successful resuscitation rates (99.02 vs. 84.15%), less ETT, and shorter MV times. However, this study was quasirandomized using a date-based randomization where LMAs were being used only on even dates and SIBs on odd dates. No information is provided regarding the blinding process. In the last of these 3 trials, Trevisanuto et al. [30] compared LMA and FM ventilation in 142 infants (born at >34 weeks’ GA and with a BW >1,500 g) assigned randomly to one of the devices. In this trial, for the first time, the LMA Supreme was used instead of the LMA Classic. The success rate of the resuscitation, which was the primary outcome, was significantly higher with the LMA Supreme than with a FM (91.5 vs. 78.9%; p = 0.03). Among the 37 patients with a BW between 1,500 and 2,000 g, the success rate was 86.7% (13/15) and 59.1% (13/22) in the LMA and FM groups, respectively (p = 0.14). Apgar score at 5 min was higher and the rate of NICU admission significantly lower in the LMA group than in the FM group (p = 0.02). The trial conducted by Feroze et al. [29] compared LMA versus ETT or FM ventilation in 75 infants with a BW >1,500 g. The rate of successful resuscitation was higher with the LMA (95%) than with the ETT (90%) and FM (80%). No difference between the devices was reported for insertion time, but the time required to achieve an effective resuscitation in the bag-mask group was twice that in the LMA group. Recently, Pejovic et al. [32] compared LMA with FM ventilation in babies >2,000 g and requiring PPV at birth in a resource-limited setting. They found that the time to spontaneous breathing (p = 0.005) and total ventilation time (p = 0.02) were shorter in the LMA arm than in the FM ventilation arm. The resuscitations were done by health staff after a short training program in neonatal resuscitation. This trial demonstrated that LMA can be used effectively by relatively inexperienced staff. In 2 other RCTs, the comparison was between LMA and ETT. Esmail et al. [26] compared the size 1 LMA and endotracheal intubation during the neonatal resuscitation of infants at a single center (Cairo University, Egypt, 1999–2000). Forty newborns, born at or after 35 weeks’ GA and delivered by CS, were assigned randomly to LMA (n = 20) or ETT (n = 20) by an anesthesiologist if their heart rate remained 34 weeks’ GA and with a BW >2,000 g, whose heart rate did not increase after 30 s of FM PPV. This was a quasi-randomized trial. There was no significant difference between groups in the rate of success for first-attempt insertion (although this was slightly higher with the LMA, i.e., 94.4 vs. 90.6% with the ETT), successful resuscitation, insertion time, response time, and ventilation time. Overall, RCTs have shown that initial respiratory management with an LMA is feasible and safe. However, there is insufficient evidence to recommend LMA for initial respiratory support in the DR, and larger randomized trials are warranted before the technique can be widely applied. Currently, there is a dearth of evidence of the use of LMA in babies