Laryngeal Mask Airway for Neonatal Resuscitation

It is fun to be able to check the “Learned Something New Today” box! Having just attended ACEP 2019 in snowy Denver, I can definitely check that box! One interesting item I learned was taught to be by our esteemed colleague, Dr. Emily MacNeill! We all know that managing the newly born can be challenging and often causes trepidation. We have discussed how best to monitor the heart rate and how that can influence neonatal resuscitation. We all know, however, that the most important aspect of helping the newly born transition to life outside the uterus is assisting with ventilation! That is often done with basic airway position, but sometimes needs positive pressure. Let’s take a minute to digest a morsel on using a Laryngeal Mask Airway (LMA) for Neonatal Resuscitation:

Laryngeal Mask Airway for Neonatal Resuscitation

  • ~10% of neonates (newly born) will require assistance with transition to extra-uterine life! [Bansal, 2018]
    • Most often this support is achieved with drying and stimulation!
    • Ventilator support may be required.
      • Good positioning and positive pressure ventilations (PPV) are the initial means of respiratory support.
      • PPV typically achieved with facemask and self-inflating bag.
      • Both of these strategies require skill and practiced technique as they can be easily done incorrectly.
  • LMA’s have been recommended in the past for [AHA Guidelines, 2015]:
    • Term and Preterm newborns at 34 weeks gestation or more in whom,
    • Tracheal intubation was unsuccessful or
    • Intubation is not feasible (ex, anatomic anomalies).
  • LMA’s may make PPV more easily and consistently achieved.
    • They can be easily inserted without laryngoscopy. [Wanous, 2017]
    • They are less negatively affected by suboptimal positioning than FM/BVM that may occur during resuscitation.
  • Size Matters:
    • LMA’s come in various sizes and these may vary slightly between manufacturers.
    • Typically, Size 1 is appropriate for newly born children who are less than 5000 grams and over 1500 grams or 34 or more weeks gestation. [Qureshi, 2018]
    • Always refer to the packaging to confirm the appropriate size.
    • There is a lack of good evidence for use of LMAs in children < 34 weeks gestation or less than 1500 grams.
  • Potential Complications: [Qureshi, 2018; Bansal, 2018; Zhu, 2011]
    • Generally determined to be safe, but can have some adverse events.
    • Gastric distention and Vomiting
    • Local soft tissue trauma
    • Difficulty suctioning
    • Improper positioning

LMA Use: For Primary Ventilation

  • Compared to facemask / BVM for PPV, use of LMAs can achieve ventilation just as effectively. [Qureshi, 2018; Pejovic, 2018; Trevisanuto, 2015]
  • LMAs have been shown to have shorter resuscitation and ventilation times when used as initial means to deliver PPV for the newly born. [Qureshi, 2018; Pejovic, 2018]

LMA Use: Alternative to ETT

  • In cases where PPV delivered via facemask / BVM does not resolve the neonate’s instability, use of LMAs lead to less need for endotracheal intubation. [Qureshi, 2018; Bansal, 2018]
  • Those who were “rescued” with LMA also have shorter ventilation time. [Qureshi, 2018]
  • Newborns resuscitated with LMA were less likely to require admission to NICU. [Qureshi, 2018]
  • LMAs were safe to use. [Qureshi, 2018]
  • LMAs have also been successfully used to administer surfactant. [Roberts,2018; Pinheiro, 2016]
  • LMAs are still recommended as the rescue device if intubation was not successful or anticipated to be unsuccessful. [AHA Guidelines, 2015]

Moral of the Morsel

  • LMAs are more than rescue devices! LMAs may be a beneficial means to deliver PPV in the newly born.
  • Know your equipment and have a plan! Look at your LMA’s packaging before you need to actually use it!
  • Learning something new is cool! Come join us at ACEP Advanced Ped EM Assembly in March.

References

Qureshi MJ1, Kumar M. Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation. Cochrane Database Syst Rev. 2018 Mar 15;3:CD003314. PMID: 29542112. [PubMed] [Read by QxMD]
Mizumoto H1, Motokura K1, Kurosaki A2, Hata D1. Introduction of laryngeal mask airway in Japan, and its rescue use for newborns. Pediatr Int. 2018 Oct;60(10):954-956. PMID: 30074665. [PubMed] [Read by QxMD]
Pejovic NJ1,2,3, Trevisanuto D4, Lubulwa C5, Myrnerts Höök S1,2,3, Cavallin F6, Byamugisha J5,7, Nankunda J5,8, Tylleskär T1. Neonatal resuscitation using a laryngeal mask airway: a randomised trial in Uganda. Arch Dis Child. 2018 Mar;103(3):255-260. PMID: 28912163. [PubMed] [Read by QxMD]
Bansal SC1, Caoci S, Dempsey E, Trevisanuto D, Roehr CC. The Laryngeal Mask Airway and Its Use in Neonatal Resuscitation: A Critical Review of Where We Are in 2017/2018. Neonatology. 2018;113(2):152-161. PMID: 29232665. [PubMed] [Read by QxMD]
Roberts KD1, Brown R2, Lampland AL3, Leone TA4, Rudser KD2, Finer NN5, Rich WD6, Merritt TA7, Czynski AJ7, Kessel JM8, Tipnis SM9, Stepka EC10, Mammel MC3. Laryngeal Mask Airway for Surfactant Administration in Neonates: A Randomized, Controlled Trial. J Pediatr. 2018 Feb;193:40-46. PMID: 29174079. [PubMed] [Read by QxMD]
Wanous AA1, Wey A, Rudser KD, Roberts KD. Feasibility of Laryngeal Mask Airway Device Placement in Neonates. Neonatology. 2017;111(3):222-227. PMID: 27866188. [PubMed] [Read by QxMD]
Pinheiro JM1, Santana-Rivas Q1, Pezzano C1,2. Randomized trial of laryngeal mask airway versus endotracheal intubation for surfactant delivery. J Perinatol. 2016 Mar;36(3):196-201. PMID: 26633145. [PubMed] [Read by QxMD]
Trevisanuto D1, Cavallin F2, Nguyen LN3, Nguyen TV3, Tran LD3, Tran CD4, Doglioni N5, Micaglio M6, Moccia L7. Supreme Laryngeal Mask Airway versus Face Mask during Neonatal Resuscitation: A Randomized Controlled Trial. J Pediatr. 2015 Aug;167(2):286-91. PMID: 26003882. [PubMed] [Read by QxMD]
Zhu XY1, Lin BC, Zhang QS, Ye HM, Yu RJ. A prospective evaluation of the efficacy of the laryngeal mask airway during neonatal resuscitation. Resuscitation. 2011 Nov;82(11):1405-9. PMID: 21763393. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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2 Responses

  1. Sean: Great summary of one of the best life saving airway adjuncts that exist. Your readers should also consider the iGel (no conflict) vs. the LMA for their supraglottic device. Some of us find it to be easier to learn how to use and to place (though a little more costly). Thanks!

    • Sean M. Fox says:

      Yes, I do like the iGel! We do use them preferentially for patients in cardiac arrest.
      This morsel was specifically about use of LMAs / supraglottic devices in the Newly Born patient… and I didn’t see much literature on the use of iGel in them.
      All the best,
      sean

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