Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation

Using a laryngeal mask, a face mask or a tube directly into the large breathing passage (endotracheal intubation) for resuscitation of a newborn infants. Most newborns are vigorous at birth, but a small number need to be helped with breathing (assisted ventilation) in the delivery room. If infants do not have effective breathing soon after birth, they can
become severely depressed, so rapidly providing effective ventilation in the delivery room is very important. Ventilation is often started using a bag with oxygen attached, that is manually pumped (manual resuscitation bag) to force air into a close-fitting face mask held over the infant's nose and mouth. If breathing remains depressed after using the manual resuscitation bag, a tube is placed directly into the infant's large airway (endotracheal intubation). Bag and mask ventilation and endotracheal intubation may not be possible when infants have airway obstructions or head and face abnormalities, obstructing the normal flow of air through the nose and mouth into the lungs and obstructing the view of the airway by the medical personnel attempting intubation. The laryngeal mask airway is an alternative to bag and mask ventilation and endotracheal intubation that uses a small mask attached to the end of a silicone tube, which can be fitted into the throat to provide positive pressure ventilation into the airway. The review authors made a thorough search of the medical literature and found one, small randomized trial (with 40 infants) that compared the laryngeal mask with endotracheal intubation, when bag and mask ventilation had been unsuccessful. There was no clinical difference between the two methods. Overall, the time taken to insert both devices was very short (7.5 to 10 sec) and the resuscitators had a very high first time success rate. No eligible randomized studies compared the laryngeal mask with bag and mask ventilation.

Authors' conclusions: 

The LMA can achieve effective ventilation during neonatal resuscitation in a time-frame consistent with current guidelines. There is no evidence to evaluate the relative efficacy and safety of the LMA compared with BMV as the primary airway device. A single, small randomised controlled trial found no clinically significant difference between the LMA and ETT when BMV was unsuccessful. Case series and case reports suggest that the LMA can provide an effective rescue airway during resuscitation if both BMV and ETT have been unsuccessful. A well-designed randomised controlled trial comparing the LMA with BMV during neonatal resuscitation is warranted.

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Background: 

Providing effective positive pressure ventilation is the single most important component of successful neonatal resuscitation. Ventilation is frequently initiated with a manual resuscitation bag and face-mask (BMV) followed by endotracheal intubation (ETT) if depression continues. These techniques may be difficult to perform successfully resulting in prolonged resuscitation or severe neonatal depression. The laryngeal mask airway (LMA) may achieve initial ventilation and successful resuscitation faster than a bag-mask device or endotracheal intubation.

Objectives: 

Among newborns requiring positive pressure ventilation for resuscitation, is effective ventilation and successful resuscitation achieved faster with the LMA compared with either BMV or ETT?

Search strategy: 

The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), MEDLINE (1966-November 2004), Pre-MEDLINE (November 15, 2004), CINAHL 1982-November 2004), reference lists of published trials, and Society for Pediatric Research abstracts were searched. Experts were contacted for additional references.

Selection criteria: 

Randomised and quasi-randomised trials

Data collection and analysis: 

Two reviewers independently evaluated studies, assessed methodologic quality, and extracted data using the Cochrane Neonatal Review Group criteria. Categorical treatment effects were described as relative risks and risk differences and continuous treatment effects were described as the mean difference. There were insufficient data to perform pooled analyses.

Main results: 

No eligible studies compared the LMA with BMV. One small randomised controlled trial comparing the LMA with ETT when BMV had been unsuccessful was included. There was no statistically significant difference between the LMA and ETT with the exception of a clinically insignificant difference in time to complete insertion of the device favouring the ETT.

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