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Lenks

Use of Laryngeal Airway Mask in preterm babies

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Hello,

I am paediatric trainee currently working in Level 2 NICU in UK. I am doing the journal club presentation about the use of LMA for administration of surfactant in preterm babies. 

During my previous placements in Level 3 NiCUs, I never seen anyone using LMAs and I was wondering what experience  do the rest of you have with using LMAs in neonates. What training did you undergo?

Thank you.

Lenka

 

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We have laryngeal masks in our "emergency" trays (also a level 2 NICU, with 8500 inborns/y) and the pediatric fellows sometimes use these during term resusc, as an alternative to intubation.

According to the manufacturer though, these masks can be used down to 1500 grams. Would be great to hear if anyone use the laryngeal mask on a regular basis for surfactant placement. I suppose it should work!

(and it seems to work according to this RCT :) https://www.ncbi.nlm.nih.gov/pubmed/29174079)

 

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We never use laryngeal mask during resuscitation. All our fellows are well trained for intubation . Even in our level 2 we never use it 

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Minimal experience using LMAs in live babies. I have used it on 2 patients. I am at a level IV NICU and we follow NRP teaching to use it in circumstances of "can't ventilate and can't intubate." We teach LMA use and placement in simulation. Its usefulness with surfactant administration in my mind is limited since it can't be used on teh smallest babies where surfactant is most beneficial. In babies >1500g it has been shown to improve short term outcomes of resuscitation compared to mask ventilation in a recent cochrane review https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003314.pub3/full?highlightAbstract=lma&highlightAbstract=neonat&highlightAbstract=neonates

I think there probably is a population of preterm and term babies >1500g at a high risk for needing PPV that might benefit from LMA use before mask to avoid intubation and further resuscitation measures. 

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 According to NRP textbook

What are the limitations of a laryngeal mask?

Laryngeal masks have several limitations to consider during neonatal resuscitation. •The device has not been studied for suctioning secretions from the airway.

•If you need to use high ventilation pressures,air may leak through the seal between the pharynx and the mask, resulting in insufficient pressure to inflate the lungs. •Few reports describe the use of a laryngeal mask during chest compressions. However, if endotracheal intubation is unsuccessful, it is reasonable to attempt compressions with the device in place.

•There is insufficient evidence to recommend using a laryngeal mask to administer intratracheal medications. Intratracheal medications may leak from the mask into the esophagus and not enter the lung. 

•Laryngeal masks can not be used in very small newborns.

Currently, the smallest laryngeal mask is intended for use in babies who weigh more than approximately 2,000 g. Many reports describe its use in babies who weigh 1,500 to 2,000 g. Some reports have described using the size-1 laryngeal mask successfully in babies who weigh less than 1,500 g.

This study by Prof Kary Roberts in USA

Laryngeal Mask Airway for Surfactant Administration in Neonates:A Randomized,ControlledTrial

 

 

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I have seen these LMAs in resuscitation carts since Pediatric Residency, but I've never seen one used. It was always emphasized during my training that any baby can be provided adequate ventilation with a bag and mask until intubation can be accomplished. Intubation skills were a priority. Of course, that was before surfactant. In the years since training I've worked in a number of L2 and L3 NICUs and never has the question of using an LMA come up. I'm intrigued, however, by the possibility of delivering surfactant without subjecting the newborn to otherwise unnecessary intubation.

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@uvbogden We teach our ped fellows in our neonatal team simulations (those sessions also include some skill training, although team communication is the core) how to use the LMA. So, we "prime" them that LMA is an easy option unless they have some experience with neonatal intubation (or until a neonatologist or anestesiologist comes and support/do the intubation). Maybe that explains why LMAs are occasionally used.

I'd estimate 1-2 infants a month get one for ventilation support in the delivery room, but given our 8500 inborns, that also means  they are rarely used despite our "priming"

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I've used an LMA for the specific indication of 'can't ventilate, can't intubate' in somewhat larger neonates (not for surfactant); we do have size 0.5 available now (I've never used them).  The only time I've used them in a DR setting was once when called emergently to a non-birthing hospital for premature triplets and I wasn't confident everyone could be intubated if BMV wasn't working.  Even in that case we ended up not giving surfactant until back in NICU and intubated.  The single biggest use case I've used an LMA for was palliative where patient is DNR/I and we're waiting for family to come in because of a decompensation and the patient REALLY needs PPV, we've placed an LMA and hooked it up to a vent until family can get in.  My experience is that families (and frankly staff) perceive this as less invasive/harmful than intubating and then pulling the ET tube when parents are there.

How was I trained?  Sim sessions in residency and fellowship and at PAS the past few years it seems there has been an airway skills workshop that I try to attend it there isn't a conflict.

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Babies with cleft palate who require intubation can pose a challenge to visualize with the usual Miller blade; so having an LMA could be helpful.

I didn't know that a size 0.5 was available, "bimalc" do you have details of brand and model? Thanks 

Bob Johnson

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The air-Qsp LMA from Cookgas is available in size 0.5. The packaging says for use <4kg. It is obviously smaller than the size 1 and certainly works when used on the prem sim babies.

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On 9/18/2018 at 1:24 AM, p_schmidt_nicu said:

The air-Qsp LMA from Cookgas is available in size 0.5. The packaging says for use <4kg. It is obviously smaller than the size 1 and certainly works when used on the prem sim babies.

Thank you for this comment! I was not aware of the 0.5

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I have used LMA once for a difficult airway where Bag and mask ventilation was ineffective and baby had Pierre robin syndrome. Intubation was difficult but my senior colleague had come and intubated and we gave surfactant only after intubation. The baby was around 1.8 kg or so.

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