Laryngeal Mask Airway (LMA) Placement in a Neonatal Patient Simulator Using a Non-Inflatable Supraglottic Airway (SGA)

Summary

This protocol is designed to describe a method to place and establish a supraglottic (alternative) airway during neonatal resuscitation. It can be used in situations where frontline providers cannot ventilate or endotracheally intubate neonates requiring resuscitation.

Abstract

The effective delivery of positive pressure ventilation (PPV) can be challenging during neonatal resuscitation. Achieving a patent airway through an appropriate interface during neonatal resuscitation is critical for avoiding airway obstruction and leakage and optimizing access to PPV. Due to the complexity of face mask ventilation, providers have explored corrective steps. However, these methods are difficult to master and thus may present a risk for ventilation delay and/or interruptions at the critical time of resuscitation and the development of complications. In addition, neonatal endotracheal intubation is an invasive procedure that requires significant practice and training. The supraglottic airway (SGA) is a useful laryngeal mask airway (LMA) interface that decreases the time required to achieve a secure airway and reduces the need for endotracheal intubation. Despite the available evidence regarding its effectiveness, insufficient training and awareness limit SGA use in the real world, and frontline providers report low confidence in SGA placement. Here we provide a detailed description of SGA placement, the instruction of which requires only minimal training and leads to a short time to proficiency. Briefly, after the administration of initial ventilatory corrective steps in a neonatal manikin, a provider inserts a non-inflatable SGA into the larynx. This method allows for a single individual to provide effective delivery of PPV in a noninvasive manner without the need for expensive equipment such as video laryngoscopy. Instructors can easily teach this technique with ease and little cost in any clinical and research setting. This is also true for different income settings, including high-, middle-, and low-income countries.

Introduction

Birth asphyxia accounts for ~1 million deaths each year and is a primary cause of early neonatal mortality¹. In high-income countries, the incidence of perinatal asphyxia is ~1/1000 live births; it can be up to 10 times higher in low-middle-income countries¹. Approximately 15%-20% of asphyxiated infants die in the first month of life and up to one-fourth of survivors sustain permanent neurologic deficits^2,3. As reported by the Centers for Disease Control and Prevention, intrauterine hypoxia and birth asphyxia account for 10% of infant mortality⁴. In the United States, 10% of all newborns need assistance in the delivery room to breathe, with less than 1% needing more advanced resuscitative measures such as cardiac compressions and medications⁵. Interventions within the first minute of life have important long-term implications for outcomes⁶.

Effective ventilation using a face mask is often challenging for those who infrequently perform neonatal resuscitation. Resultant hypoxia, bradycardia, and emergent tracheal intubation increase unanticipated neonatal intensive care unit (NICU) admissions. The most common problems associated with a poor face mask technique include mask leakage, air blockage, and insufficient chest excursion^7,8,9. NRP includes ventilation corrective steps, but mastery of these skills is difficult if not performed often.

The American Heart Association and American Academy of Pediatrics developed the Neonatal Resuscitation Program (NRP) to teach an evidence-based approach to newborn care. The NRP algorithm calls for tracheal intubation when face mask ventilation is ineffective or prolonged⁵. However, pediatric trainees have also shown difficulty performing intubation and have few opportunities to practice^10,11,12. An SGA is an appropriate alternative airway in newborns weighing >1500 g when face mask ventilation is insufficient and endotracheal intubation is unsuccessful or not feasible^13,14,15,16. Although many studies support the feasibility and utility of SGA for initial respiratory management in low-middle-income countries, there is a paucity of data to support the use of SGA to perform initial PPV in high-income countries^9,10,11.

We speculate that the mastery of SGA use has the potential to reduce PPV interruptions and therefore improve resuscitation outcomes. Our overarching objective was to evaluate the effectiveness of focused SGA training on newborn resuscitation outcomes, including PPV duration, ventilation failures, and complications.

Protocol

All methods described here have been approved by the Institutional Review Board of the University of Oklahoma Health Sciences Center.

1. Placing a laryngeal mask

1. Select appropriately sized SGA (newborn size 1 [2-5 kg]).
2. Open the SGA. Remove the pack that holds the device.
3. Open the pack. Transfer the SGA to the lid of the pack.
4. Holding the integral bite block, apply a thin coat of lubricant to the back, sides, and the front of the SGA.
   1. Check for boluses of lubricant and remove them if necessary.
   2. Take care to avoid contact with the cuff of the device.
5. Inspect the device carefully.
   1. Check for foreign bodies or a bolus of lubricant obstructing the distal opening, and return the SGA into the cage pack.
6. Always wear gloves.
7. Decompress the stomach with an orogastric tube as needed.
8. Remove the SGA from the container.
9. Hold the lubricated SGA firmly.
10. Stand at the baby's head. Position the device such that the cuff outlet is facing the chin of the baby. Ensure that the baby is in the 'sniffing' position with the head extended and the neck flexed. Gently open the mouth and press down on the chin before proceeding.
11. Press the leading soft tip into the mouth against the baby's hard palate on the top of the baby's tongue. Maintain pressure against the palate.
    1. Advance the device inward to follow the contour of the mouth and palate with a continuous but gentle slide until resistance is felt.
    2. Arrange the tip of the airway into the upper esophagus, positioning the cuff against the laryngeal framework.

2. Confirming correct placement

1. Attach the carbon dioxide (CO₂) detector and connect it to the PPV device.
2. After the correct placement, ensure that there is a bilateral chest movement with ventilation and hear equal breath sounds.
3. If this intervention is successful, notice an increase in heart rate and oxygen saturation.
4. By the time of providing 8-10 breaths, ensure that the CO₂ detector turns yellow as it detects exhaled CO₂.

3. Anchoring the laryngeal mask

1. Secure the SGA down from maxilla to maxilla with tape.
2. Monitor heart rate, oxygen saturation, breathing, and muscle tone. The newborn can cry and make sounds with the SGA in place.

4. Removing the laryngeal mask

1. If one decides to remove the laryngeal mask, use bulb suction or suction catheter to remove secretions from the mouth and throat.
2. Then, remove the SGA device.
3. Monitor heart rate, breathing, and oxygen saturation.

Representative Results

Following successful SGA placement, effective PPV can be confirmed by listening for air entry bilaterally in the lungs and visualizing chest wall movement with ventilation (Figure 1). Occasionally, an incorrect position can result in ineffective lung aeration, resulting in failure to raise heart rate, improvements in oxygen saturation, and a color change to yellow on the CO₂ colorimeter.

A recent case series¹⁷ at our institution's facilities detailed the use of supraglottic airway placement in the delivery room and neonatal resuscitation in real life. Initial insertion was successful and provided immediate stabilization in all cases, with avoidance of NICU admission noted in 38% of cases when used at birth (Table 1). The only notable complication was a necessary reinsertion due to the triggering of the newborn gag reflex by excessive secretions.

Figure 1: Confirming effective PPV. Following successful SGA placement, listen for air entry bilaterally in the lungs and visualize chest wall movement with ventilation to confirm effective PPV. Please click here to view a larger version of this figure.

Table 1: Cohort of newborns receiving supraglottic airway intervention. This table has been adapted with permission from White et al.¹⁷. Please click here to download this Table.

Discussion

Training in newborn resuscitation can reduce term intrapartum-related deaths by 30%¹⁸. The Oklahoma Children's Hospital at University of Oklahoma (OU) Health, located on the campus of the University of Oklahoma Health Sciences Center in Oklahoma City, OK, requires all healthcare providers who assist in the management of newborns to maintain up-to-date NRP training. According to the current NRP guidelines, the most vital aspect of neonatal resuscitation is the effective delivery of positive pressure ventilation (PPV)^13,17.

While providers can likely predict the necessity of positive pressure ventilation in many cases due to certain risk factors, preliminary observations revealed that 30% of newborns receive unanticipated PPV¹⁹. Additionally, interruptions in ventilation occur in up to 56% of newborns receiving PPV²⁰. Disrupted ventilation leads to prolonged PPV, bradycardia, decreased Apgar scores, delivery room tracheal intubation by the advanced resuscitation team, and unintended NICU admissions. However, timely and effective face mask ventilation and/or tracheal intubation during resuscitation are difficult skills to master and often lacking in frontline personnel^{21,22,23,24,25}. In a recent national United Kingdom survey conducted among general pediatric neonatal trainees and advanced neonatal nurse practitioners, only 18% of all respondents reported complete confidence with intubation²⁵. The first intubation attempt in the delivery room has a success rate of 46% while conveying a 17% adverse event rate (tube malposition, bradycardia, trauma, etc.) and a 31% severe oxygen desaturation rate²⁶. The learning curve for endotracheal intubation is complex and requires 58 attempts to achieve a success rate of 90%²⁷. Collectively, these challenges prolong resuscitation efforts and/or neonatal asphyxia while awaiting the arrival of an advanced resuscitation team¹³.

SGA may be a viable alternative to tracheal intubation to solve challenges with universal intubation competency²⁵. However, we recently found a low level of confidence in SGA placement reported by frontline neonatal resuscitation providers, with insufficient training being one of the frequently cited barriers¹⁶. As seen in the protocol, providers can easily place an SGA and provide PPV. A Ugandan randomized controlled trial demonstrated that PPV duration was significantly shorter when using the SGA than when using the face mask (93 s vs. 140 s)²⁸. Effective use of an SGA may reduce the need for endotracheal intubation (and the risks associated with this procedure), as demonstrated in a recent meta-analysis. The same study also showed a decrease in the duration of PPV and time until the heart rate exceeded 100 beats/min when using SGA²⁹. Newborns resuscitated with SGAs required fewer NICU admissions than newborns who received face mask ventilation²⁴. Finally, some congenital craniofacial or airway anomalies make the use of traditional ventilation methods difficult or impossible; the use of an SGA is the first choice for the establishment of effective ventilation¹⁰.

There are limitations to the use of SGAs. As the need for PPV increases as gestational age decreases, the size limitation (>1.5 kg) of the SGA can be a limiting factor in its utility. Also, researchers explore an optimal approach to the use of SGA for the administration of endotracheal medications (such as surfactant and epinephrine) only in approved clinical trials. Specifically, referring to the protocol, users may find some difficulty with the insertion of SGA. Reapplying a layer of lubricant can remedy this situation, although in vivo use of the lubricant would likely be unneeded due to a newborn's natural oropharyngeal lubrication.

Based on the literature and the utility of the protocol, we believe that there can be many applications of SGA in the stabilization and resuscitation of appropriate newborns. With the increasing use of aerosolized surfactants, administration of this medication via SGA may be feasible in the near future. This would further enforce the utility of this alternate airway.

Materials

Name	Company	Catalog Number	Comments
CO2 detector	Medtronic USA	42271500	Nellcor pediatric colorimetric CO2 detector (pedicap)
I-gel supraglottic airway	Intersurgical	8201000	Neonatal size # 1
Lubricant	Laerdal Medical AS	252090	Airway Lubricant Spray Can (180 mL)
Neonatal Patient Simulator	Laerdal Medical AS	296-00050	SimNewB Light tetherless
Positive pressure ventilation device	Fisher & Paykel Healthcare	RD900	Neopuff Infant T-Piece Resuscitator