Elsevier

Resuscitation

Volume 62, Issue 2, August 2004, Pages 151-157
Resuscitation

Laryngeal mask airway: is the management of neonates requiring positive pressure ventilation at birth changing?

https://doi.org/10.1016/j.resuscitation.2004.03.006Get rights and content

Abstract

Objective: To evaluate the impact of the laryngeal mask airway (LMA) on neonatal resuscitation policy. Design: We analyzed retrospectively the records of neonates requiring positive pressure ventilation (PPV) at birth before (1996) and after (2000) the introduction of the LMA into our delivery suites. In addition, the outcome of neonates treated with the LMA was compared with that of neonates matched for gestational age and mode of delivery who were resuscitated using a face mask. Results: During the year 2000, 95 out of 380 (25%) resuscitated neonates were treated with the LMA. The LMA was effective in 94 out of 95 (99%) of these infants. Over the same period, the percentage of neonates receiving tracheal intubation (TI) at birth (34%) was significantly reduced compared with the figure for 1996 (67%). There were no reported complications associated with the use of the LMA. Seventy-four out of the 95 neonates treated with the LMA were considered suitable for matching for gestational age and mode of delivery with 74 neonates treated with a face mask. No differences were found between the two groups for birth weight, Apgar scores, need for tracheal intubation, need for admission to the Neonatal Intensive Care Unit (NICU), primary diagnosis at discharge and primary outcomes. The LMA provided effective ventilation in four neonates in whom the face mask failed. Conclusions: The LMA is changing neonatal resuscitation practice in our Institution. Our data suggest that it is a safe and useful alternative method for respiratory support in neonates requiring PPV at birth, which merits further study.

Sumàrio

Objectivo:Avaliar o impacto da máscara ları́ngea (LMA) na polı́tica de reanimação do recém-nascido. Desenho: Analisámos de forma retrospectiva os registos de recém-nascidos que necessitaram de ventilação com pressão positiva (PPV) ao nascimento antes (1996) e após (2000) a introdução da LMA nas unidades de parto. O prognóstico dos recém-nascidos tratados com LMA foi comparável ao dos recém-nascido com a mesma idade gestacional e com o mesmo modo de nascimento reanimados com máscara facial. Resultados:Durante o ano de 2000, 95 dos 380 (25%) recém-nascidos foram tratados com LMA. A LMA foi eficaz em 94 de 95 (99%) destes lactentes. Durante o mesmo perı́odo, a percentagem de recém-nascidos que são submetidos a Entubação Traqueal (ET) ao nascimento (34%) foi significativamente reduzida comparativamente com os dados de 1996 (67%). Não foi relatada nenhuma complicação associada à utilização da LMA. Setenta e quatro dos 95 recém-nascidos tratados com LMA foram considerados elegı́veis para cruzar em termos de idade gestacional e modo de nascimento com 74 recém-nascidos tratados com máscara facial. Não foram encontradas diferenças entre os dois grupos quanto ao peso ao nascimento, indice de Apgar, necessidade de entubação traqueal, necessidade de admissão na Unidade de Cuidados Intensivos Neonatais (NICU), diagnóstico à alta e outcome primário. A LMA permitiu ventilação eficaz em quatro recém-nascidos nos quais a máscara facial falhou. Conclusão:A LMA está a alterar a prática da reanimação neonatal na nossa instituição. Os nossos dados sugerem que é um método alternativo seguro e útil para suporte ventilatório em recém-nascidos que necessitem de PPV ao nascimento, e que devem ser feitos mais estudos.

Resumen

Objetivo: Evaluar el impacto de la Mascara ları́ngea (MLA) en la polı́tica de reanimación neonatal. Diseño: Analizamos retrospectivamente los registros de los neonatos que requirieron ventilación a presión positiva (PPV) al momento de nacer antes (1996) y después (2000) de la introducción de la LMA a las salas de parto. Se comparó además, el resultado de neonatos tratados con LMA con aquellos de neonatos reanimados con mascara facial, equiparados por edad gestacional y tipo de parto. Resultados: Durante el año 2000, 95 de 380 (25%) de los neonatos resucitados fueron tratados con LMA. La LMA fue efectiva en 94 de 95 (99%) de estos infantes. En ese mismo perı́odo, el porcentaje de neonatos que recibieron intubación traqueal (TI) al momento de nacer (34%) se redujo significativamente comparado con las cifras de 1996 (67%). No se reportaron complicaciones asociadas con el uso de la LMA. Setenta y cuatro de los 95 neonatos tratados con la LMA se consideraron adecuados para equipararse por edad gestacional y tipo de parto con 74 neonatos tratados con máscara facial. No se encontraron diferencias entre los dos grupos en el peso al nacer, puntaje de APGAR; necesidad de intubación traqueal, necesidad de admisión en la unidad de terapia intensiva neonatal, diagnóstico primario al momento del alta ni en resultados. La LMA proporcionó ventilación efectiva en 4 neonatos en quienes falló la máscara facial. Conclusiones: La LMA está cambiando la práctica de reanimación neonatal en nuestra institución. Nuestros datos sugieren que es una alternativa útil y segura para apoyo respiratorio en neonatos que requieren ventilación a presión positiva al momento de nacer, lo que hace necesario ulterior estudio.

Introduction

Approximately 5–10% of the newly-born population require some degree of active resuscitation at birth [1], [2]. The cornerstone of neonatal resuscitation is rapid establishment of a patent airway and effective ventilation. Generally, this is accomplished with bag-mask ventilation (BMV) or tracheal intubation (TI) and positive pressure ventilation (PPV) [1], [2]. However, success with these techniques sometimes may be impossible, especially in neonates with congenital airway malformations. In these situations, the laryngeal mask airway (LMA) may be lifesaving [3]. The LMA, developed between 1981 and 1987 by Brain, became available to anaesthesiologists in 1988 for clinical use in adults and subsequently in paediatric patients [4] (Fig. 1).

In adult patients, the LMA offers many advantages when compared to the face mask which include easier placement by inexperienced personnel, improved oxygen saturation, and less hand fatigue. It has been reported to improve operating conditions during minor paediatric otological surgery [5]. In adults, the LMA circumvents the need for an oral airway which, however, is often not used when neonates are resuscitated using a face mask [1], [2].

Compared with tracheal intubation (TI) in adults, the reported advantages of the LMA are: increased speed and ease of placement by inexperienced personnel, increased speed of placement by anaesthetists, improved haemodynamic stability at induction and during emergence, improved oxygen saturation during emergence and a reduced incidence of sore throat [5].

On the other hand, it should be born in mind that there are limitations to the use of the LMA in adults, for example, when higher airway pressures are required. This does occur in neonates with low-compliance lung disease. In addition, gastric insufflation, aspiration, and the difficulty of suctioning the airway or administrating drugs tracheally are other potential disadvantages related to the use of this device in adults and neonates. Furthermore, the size-1 LMA may be inadequate for administering PPV in low birth-weight infants. Finally, if pharyngo-laryngeal reflexes are present, the positioning of the LMA may lead to glottic closure simulating laryngospasm.

However, in a majority of neonatal patients, the LMA could be an effective alternative to the face mask in administering PPV at birth, possibly reducing the need for TI. Although several case reports describing its use in neonatal patients have been published, [3], [6], [7] only two limited case series (from two centres) have been reported to date [8], [9]. In a recent paper, its use throughout a whole region was documented [10].

Thus, only limited data are currently available concerning the use of this device in neonatal resuscitation.

Until 1996, at the University of Padova in Italy, the standard treatment of neonates requiring PPV at birth included immediate ventilation either by face mask or by TI. However, attempting to obtain effective PPV at birth and possibly to reduce the subsequent need for TI, since 1997, the LMA has been introduced progressively into our delivery rooms as a device for the application of PPV in neonates. By 2000, this ventilation strategy was being widely used by all our physicians [11].

The aims of this retrospective observational study were two-fold:

  • (1)

    to compare the data of the neonates needing PPV born in 1996 in our institution, the last year of conventional ventilation policy (BMV and TI), with the data obtained in 2000, the first year after definitive implementation of LMA use for neonatal airway management (Part I); and

  • (2)

    to compare the characteristics and the outcome of neonates treated with this new device with those of neonates managed using more conventional forms of airway management (Part II).

Section snippets

Neonatal resuscitation protocol and training

Neonatal resuscitation in the delivery room was performed according to the International Guidelines for Neonatal Resuscitation [1], [2]. However, if the neonate required PPV for apnoea and/or bradycardia <100 beats/min, the LMA was considered suitable for airway management.

In 1996, we developed an educational programme for personnel involved in neonatal resuscitation based on the American Heart Association and American Academy of Pediatrics’s Neonatal Resuscitation Manual. In these 2-day

Part I: Comparative analysis of current with previous practice in Padova (1996 versus 2000)

Neonates needing resuscitation at birth were 421/3238 (13%) and 380/3454 (11%) in 1996 and 2000, respectively. In 1996, the number of newborns treated with BMV was significantly lower than in 2000: 139 (33%) versus 156 (41%), P=0.018. In 1996, the number of neonates receiving TI was significantly higher than in 2000: 282 (67%) versus 129 (34%), P<0.001. In 1996 the LMA was not used, while in 2000 the LMA was used in 95 neonates (25%), P<0.001. (Fig. 2).

Ten physicians were involved in LMA

Discussion

The LMA has been recommended by the American Heart Association and the European Resuscitation Council for use in adult resuscitation, [13] and it has been suggested that it may have a role in neonatal resuscitation [3], [4]. International Guidelines on neonatal resuscitation suggest that this device “may be an effective alternative for establishing an airway during resuscitation of the newly born infant, particularly if BMV is ineffective or attempts at TI have failed” [1]. However, routine use

Conclusions

Although routine use of the LMA for neonatal resuscitation cannot be recommended at this time, our observational study shows that this device could be an effective alternative to more conventional forms of airway management in term infants needing PPV at birth. Prospective randomised trials are needed to clarify the potential role of the LMA in neonatal resuscitation [19].

Acknowledgements

The authors thank Chandy Verghese, MD, and Archie IJ Brain, MD, the inventor of the LMA (Royal Berkshire Hospital, Reading, UK) for their critical review of this manuscript.

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