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