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.

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'...

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 pre...

Materials

List of materials used in this article

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