Supraglottic airway devices during neonatal resuscitation: An historical perspective, systematic review and meta-analysis of available clinical trials

Abstract

Introduction

Various supraglottic airway devices are routinely used to maintain airway patency in children and adults. However, oropharyngeal airways or laryngeal masks (LM) are not routinely used during neonatal resuscitation.

Methods

The aim of this article was to review the available literature about the use of supraglottic airway devices during neonatal resuscitation. We reviewed books, resuscitation manuals and articles from 1830 to the present using the search terms “Infant”, “Newborn”, “Delivery Room”, “Resuscitation”, “Airway management”, “Positive Pressure Respiration”, “Oropharyngeal Airway” and “Laryngeal Mask”.

Results

No study was identified using oropharyngeal airways during neonatal resuscitation. Four trials including 509 infants compared positive pressure ventilation with a LM, bag and mask or an endotracheal tube. Infants in the LM group were intubated less frequently compared to infants in the bag and mask ventilation group 4/275 vs. 28/234 (OR 0.13, 95% CI 0.05–0.34). Infants resuscitated with the LM had significantly less unsuccessful resuscitations 4/275 vs. 31/234 (OR 0.10, 95% CI 0.03–0.28). Two trials including 34 preterm infants compared surfactant administration via LM vs. endotracheal tube. LM surfactant administration was safe and no adverse events were reported.

Conclusion

The efficacy and safety of oropharyngeal airways during neonatal resuscitation remain unclear and randomized trials are required. The current evidence suggests that resuscitation with a LM is a feasible and safe alternative to mask ventilation in infants >34 weeks gestation and birth weight >2000 g. However, further randomized control trials are needed to evaluate short- and long-term outcomes following use of laryngeal masks. In addition, surfactant administration via LM should be used only within clinical trials.

Introduction

Approximately 10% of newborn infants require some form of respiratory support in first minutes after birth.¹ The International Liaison Committee on Resuscitation (ILCOR) and various national guidelines recommend techniques and equipment for neonatal resuscitation.2, 3, 4, 5 They all agree that mask ventilation is the cornerstone of respiratory support immediately after birth.2, 3, 4, 5 However, several factors can reduce the effectiveness of mask ventilation, including poor face mask technique resulting in leak or airway obstruction, spontaneous movements of the baby, movements by or distraction of the resuscitator, and procedures such as changing the wraps or fitting a hat.6, 7, 8 Delivery room studies have shown that mask ventilation is difficult and mask leak and airway obstruction are common.6, 7, 9, 10 Various airway maneuvers (e.g. neutral position, chin lift or jaw thrust) have been recommended to optimize mask ventilation and reduce airway obstruction.⁸ Resuscitation guidelines suggest that ‘in floppy babies application of jaw thrust or the use of an appropriately sized oropharyngeal airway, which may be helpful in opening the airway’.⁴ Although oropharyngeal airways are frequently used for airway patency in children and adults,11, 12, 13 none are routinely used during neonatal resuscitation.

Archie Brain, a British anesthetist, described the laryngeal mask (LM) as an alternative to endotracheal intubation in 1981.¹⁴ The LM consists of an airway tube connected distally to a soft elliptical mask with an inflatable rim to fit over the laryngeal inlet whereas the proximal end connects to the positive pressure ventilation device.¹⁴ A LM provides an alternative in difficult airway scenario where either mask ventilation is ineffective or intubation impossible.¹⁵ Currently LMs are routinely used by paramedics, emergency rooms and operating theaters for adult and pediatric anesthesia.12, 16, 17 In newborn infants, the evidence is mainly derived from case series and observational studies,18, 19 suggesting that a LM can provide an effective rescue airway during resuscitation if both mask ventilation and endotracheal intubation have been unsuccessful. Current neonatal resuscitation guidelines recommend use of LM in newborn infants >34 weeks gestation or >2000 g birth weight when face mask ventilation or tracheal intubation is unsuccessful or not feasible.2, 4 In addition, use of LMs have been reported during neonatal transport,20, 21, 22 provision of prolonged mechanical ventilation in particular for infants with upper airway abnormalities,23, 24, 25, 26, 27 and administration of intratracheal medications.28, 29, 30, 31, 32 Although, LMs are recommended by various neonatal resuscitation guidelines,2, 3, 4 if mask ventilation or endotracheal intubation have been unsuccessful, they are not routinely used during neonatal resuscitation.

The aim of this article was to review the available literature on the use of oropharyngeal airways and laryngeal mask airway during neonatal resuscitation.