Airway support during neonatal resuscitation: how effective is a laryngeal mask?

Abstract

Commentary on: Trevisanuto D, Cavallin F, Nguyen LN, Nguyen TV, Tran LD, Tran CD, Doglioni N, Micaglio M, Moccia L. Supreme laryngeal mask airway versus face mask during neonatal resuscitation: a randomized controlled trial. J Pediatr 2015;167: 286–91.e1. doi:10.1016/j.jpeds.2015.04.051 Laryngeal mask airways (LMA) have been available as useful adjuncts in airway management for adults and children. However, only recently have potential benefits been recognised in neonates and advancing technology has enabled the production of devices suitable for smaller, more fragile airways. Evidence from studies in term and larger preterm infants 1 has lead to international newborn resuscitation guidelines suggesting that laryngeal masks might be considered for use in babies >2000 g where facemask ventilation is unsuccessful or is not feasible 2. The supreme laryngeal mask (SLMA) used in this study has potential advantages over the classical LMA that has been more widely used previously. Previous research has been mainly observational 3, 4 and mostly in the field of anaesthesia. This study adds to the accumulating literature by using a randomised design and by broadening the inclusion criteria. This trial included infants from 1500 g birthweight. The results are in line with previous research, suggesting LMAs can offer benefit over facemasks in reducing the need for intubation in the first minutes of life without introducing unwanted complications. In those babies born between 1500 and 2000 g, there was also a high rate of success with the device. However, the number of babies requiring intubation [13/15 (86.7%) SLMA vs 13/22 face mask (59.1%)] was somewhat higher than that previously reported with the use of a classical LMA, suggesting further work is needed to identify the optimum device for use in neonates. The use of LMA for resuscitation is attractive for a number of reasons. Firstly, for resource-poor countries, it introduces new possibilities for infants requiring a safe alternative for securing the airway postdelivery where the option of ventilation is not available 5. In such settings, large numbers of late preterm and early term babies stand to benefit, as well as those born at full term who require more than the most basic support and stabilisation. Changes in the practice of neonatal medicine brought about by the introduction of surfactant, antenatal corticosteroids and noninvasive respiratory support mean fewer infants are ventilated in neonatal intensive care units in developed countries. For those requiring mechanical ventilation, the duration is generally kept to a minimum. We therefore find ourselves in a situation where the opportunities to learn and refine intubation skills are fewer, and the experience of junior clinicians delivering ‘front-line’ support at the time of delivery is considerably more limited than in the past 6, 7. The addition of alternative means to maintain a challenging airway is equally attractive in this environment. It seems reasonable that LMAs should be available for use in neonatal resuscitation and that staff caring for newborn infants should be trained in their use. One caveat is that, despite availability of effective and less invasive devices, we should not overlook the need to ensure adequate training in intubation for those attending deliveries. There will always be babies for whom optimum management will require more intensive intervention – we must work to maintain the skills needed to deliver this safely, effectively and in a timely way. https://ebneo.org/2015/09/airway-support-during-neonatal-resuscitation-how-effective-is-a-laryngeal-mask/ None. None.