Neonatal Resuscitation with the Laryngeal Mask Airway in Normal and Low Birth

Weight Infants
Gandini, Donna MB, BS*; Brimacombe, Joseph R. MB, ChB, FRCA, MD
Article Outline
Collapse BoxAuthor Information
Departments of *Paediatrics and Anaesthesia and Intensive Care, University of
Queensland, Cairns Base Hospital, Cairns, Australia
April 26, 1999.
Address correspondence and reprint requests to Dr. J. Brimacombe, Department
of Anaesthesia and Intensive Care, Cairns Base Hospital, Cairns 4870, Australia.
Address e-mail to 100236,2343@compuserve.com.
Published, in part, in Pediatrics 1995;95:4534.
Maintenance of a clear airway is the primary objective of neonatal resuscitation
and is currently achieved via either a face mask or tracheal tube (1). The
laryngeal mask airway (LMA) has a potential role in neonatal resuscitation as an
alternative to the face mask and for difficult airway management (2), but
published data are limited. Paterson et al. (3) described its successful use in 21
neonates weighing >2.5 kg. Margaria et al. (4) showed that oxygen saturation
increased more rapidly with the LMA than with the face mask in 100 neonates,
but demographic details were lacking. The size 1 LMA is currently recommended
for infants <5 kg (5), but its use in neonates <2.5 kg has only been reported
anecdotally (6). The objective of this prospective observational study was to
evaluate LMA use by a single pediatric resident in normal and low birth weight
(<2.5 kg) neonates requiring positive pressure ventilation (PPV) during
resuscitation.
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Methods
With ethics committee approval, we studied LMA use for neonatal resuscitation
for 5 yr. In our institute, the LMA has been a standard of care for neonatal
resuscitation since 1994. After delivery, neonates were transferred to a standard
neonatal resuscitation cart and were included in the study if they required PPV
for apnea or a heart rate <100 bpm (7). Clinical assessment of heart rate,
respiratory effort, and skin color (under a constant level of light) was made
continually once the neonate was on the resuscitation cart. Heart rate was
determined by palpation of the apex beat and repeatedly counting beats in 3-s
blocks (if the count was <5, heart rate was <100 bpm). Neonates with
meconium-stained fluid underwent laryngoscopy before PPV was commenced
and were excluded if they had evidence of meconium aspiration. All insertions
were performed by one of the authors (DG). Training included five uses of the
LMA in neonatal resuscitation. The size 1 LMA was inserted and fixed using the

recommended technique (5). No lubrication was used due to the wetness of the
neonatal oropharynx. The LMA cuff was inflated with 14 mL of air, held in place
manually, and connected to an anesthesia breathing system with 100% oxygen
at a flow rate of 12 L/min. PPV at a rate of 6080 breaths/min was commenced
while the neonate was dried and warmed by an assistant. Airway pressures were
limited to 40 cm H2O. The airway pressure at which an audible leak occurred was
recorded (8). Gastric insufflation was assessed by epigastric stethoscopy. If
adequate chest expansion with PPV was not obtained after two insertion
attempts, either a face mask or a tracheal tube was to be used. When
spontaneous breathing commenced, continuous positive airway pressure at 510
cm H2O was provided until breathing became regular. The LMA was removed
when the neonate rejected it. If there was any subsequent deterioration in heart
rate or respiratory effort, the LMA was reinserted. If the neonate required PPV for
>15 min, the LMA was removed and the trachea intubated.The following data
were collected by assisting midwives trained in the study protocol: mode of
delivery; delivery to resuscitation time (umbilicus cut to start of resuscitation);
the number of insertion attempts; audible leak pressure; and the time from start
of resuscitation to achieve 1) adequate chest expansion, 2) a heart rate 100
bpm, 3) a pink trunk, 4) regular breathing, and 5) LMA removal. Apgar scores
were recorded 1 and 5 min postdelivery. The number of neonates requiring LMA
reinsertion or intubation was recorded. Time zero for start of resuscitation was
recorded from when the LMA was picked up for the first insertion
attempt.Statistical analysis was performed by using a paired t-test, Friedmans
two-way analysis of variance, and a 2 test. Significance was taken as P < 0.05.
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Results
The investigator attended 689 deliveries over the study period. One hundred
thirty neonates were apneic or had a heart rate <100 bpm at delivery. Thirty-five
had meconium-stained fluid. Twenty-six had evidence of meconium aspiration
and were intubated tracheally. One hundred four neonates met the inclusion
criteria. Comparative data are presented in Table 1. One hundred three (99%)
neonates were successfully resuscitated. Low birth weight neonates were more
frequently premature and required more PPV >15 min, but there were no other
differences between the groups. Six neonates delivered by cesarean section
under general anesthesia required LMA reinsertion after successful resuscitation
due to central hypoventilation. Six neonates resuscitated with the LMA
subsequently developed respiratory distress syndrome 30120 min postdelivery
and required nasopharyngeal continuous positive airway pressure (n = 2),
tracheal intubation for PPV, and/or administration of surfactant (n = 4). There
was no gastric insufflation or pneumothoraces. In one 3.5-kg neonate with no
meconium staining, LMA insertion was readily achieved, but PPV was impossible.
The LMA was immediately removed and the trachea intubated. PPV remained
impossible, and this unexpected stillbirth was found to have severe meconium
aspiration at postmortem.

Discussion
Paterson et al. (3) showed that a clear airway could be obtained with the LMA in
nine seconds and that oxygenation could be restored in 30 seconds. Margaria et
al. (4) showed that insertion time was two seconds and that oxygen saturation
was >90% within five minutes. Our results support these findings and show that
the LMA may be used in low birth weight neonates, including neonates weighing
11.5 kg. Our values for audible leak pressure were similar to those reported by
Paterson et al. (3), at approximately 23 cm H2O. Most apneic neonates with
normal lungs require <25 cm H2O for initial lung expansion (9). The LMA may be
unsuitable for PPV in neonates who have low compliance lung pathology because
higher airway pressures may be required. However, the low-pressure seal formed
with the pharynx will protect normal lungs from barotrauma. The LMA is
unsuitable for neonates with meconium aspiration because a suction catheter
cannot be reliably passed into the lungs without fiberoptic guidance, and there
may be coexisting lung pathology. We conclude that the LMA can be used for PPV
in normal and low birth weight neonates requiring resuscitation. Its reliability
when used by multiple users or inexperienced personnel is unknown.
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