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Meta-Analysis
. 2018 Mar 15;3(3):CD003314.
doi: 10.1002/14651858.CD003314.pub3.

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

Mosarrat J Qureshi  1 , Manoj Kumar
Affiliations
Meta-Analysis

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

Mosarrat J Qureshi et al. Cochrane Database Syst Rev. .

Abstract

Background: Providing effective positive pressure ventilation is considered to be the single most important component of successful neonatal resuscitation. Ventilation is frequently initiated manually with bag and face mask (BMV) followed by endotracheal intubation if respiratory depression continues. These techniques may be difficult to perform successfully resulting in prolonged resuscitation or neonatal asphyxia. 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 cardio-pulmonary resuscitation, is LMA more effective than BMV or endotracheal intubation for successful resuscitation? When BMV is either insufficient or ineffective, is effective positive pressure ventilation and successful resuscitation achieved faster with the LMA compared to endotracheal intubation?

Search methods: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1), MEDLINE via PubMed (1966 to 15 February 2017), Embase (1980 to 15 February 2017), and CINAHL (1982 to 15 February 2017). We also searched clinical trials registers, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

Selection criteria: We included randomised and quasi-randomised controlled trials that compared LMA for neonatal resuscitation with either BMV or endotracheal intubation and reported on any outcomes related to neonatal resuscitation specified in this review.

Data collection and analysis: Two review authors independently evaluated studies for risk of bias assessments, and extracted data using Cochrane Neonatal criteria. Categorical treatment effects were described as relative risks and continuous treatment effects were described as the mean difference, with 95% confidence intervals (95% CI) of estimates.

Main results: We included seven trials that involved a total of 794 infants. Five studies compared LMA with BMV and three studies compared LMA with endotracheal intubation. We added six new studies for this update (754 infants).LMA was associated with less need for endotracheal intubation than BMV (typical risk ratio (RR) 0.24, 95% CI 0.12 to 0.47 and typical risk difference (RD) -0.14, 95% CI -0.14 to -0.06; 5 studies, 661 infants; moderate-quality evidence) and shorter ventilation time (mean difference (MD) -18.90 seconds, 95% CI -24.35 to -13.44; 4 studies, 610 infants). Babies resuscitated with LMA were less likely to require admission to neonatal intensive care unit (NICU) (typical RR 0.60, 95% CI 0.40 to 0.90 and typical RD -0.18, 95% CI -0.31 to -0.04; 2 studies,191 infants; moderate-quality evidence). There was no difference in deaths or hypoxic ischaemic encephalopathy (HIE) events.Compared to endotracheal intubation, there were no clinically significant differences in insertion time or failure to correctly insert the device (typical RR 0.95, 95% CI 0.17 to 5.42; 3 studies, 158 infants; very low-quality evidence). There was no difference in deaths or HIE events.

Authors' conclusions: LMA can achieve effective ventilation during neonatal resuscitation in a time frame consistent with current neonatal resuscitation guidelines. Compared to BMV, LMA is more effective in terms of shorter resuscitation and ventilation times, and less need for endotracheal intubation (low- to moderate-quality evidence). However, in trials comparing LMA with BMV, over 80% of infants in both trial arms responded to the allocated intervention. In studies that allowed LMA rescue of infants failing with BMV, it was possible to avoid intubation in the majority. It is important that the clinical community resorts to the use of LMA more proactively to provide effective ventilation when newborn is not responding to BMV before attempting intubation or initiating chest compressions.LMA was found to offer comparable efficacy to endotracheal intubation (very low- to low-quality evidence). It therefore offers an alternate airway device when attempts at inserting endotracheal intubation are unsuccessful during resuscitation.Most studies enrolled infants with birth weight over 1500 g or 34 or more weeks' gestation. As such, there is lack of evidence to support LMA use in more premature infants.

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Conflict of interest statement

None

Figures

1
1
Study flow diagram: LMA versus BMV or endotracheal intubation for neonatal resuscitation review update
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 LMA versus BMV, Outcome 1 Failure with primary modality of resuscitation.
1.2
1.2. Analysis
Comparison 1 LMA versus BMV, Outcome 2 Need for intubation.
1.3
1.3. Analysis
Comparison 1 LMA versus BMV, Outcome 3 Time to spontaneous breathing.
1.4
1.4. Analysis
Comparison 1 LMA versus BMV, Outcome 4 Ventilation time [seconds].
1.5
1.5. Analysis
Comparison 1 LMA versus BMV, Outcome 5 Apgar score ≤ 7 at 5 min.
1.6
1.6. Analysis
Comparison 1 LMA versus BMV, Outcome 6 Admission to NICU.
1.7
1.7. Analysis
Comparison 1 LMA versus BMV, Outcome 7 Death or HIE.
2.1
2.1. Analysis
Comparison 2 LMA versus endotracheal intubation, Outcome 1 Failure to correctly insert the device.
2.2
2.2. Analysis
Comparison 2 LMA versus endotracheal intubation, Outcome 2 Successful insertion of device at first attempt.
2.3
2.3. Analysis
Comparison 2 LMA versus endotracheal intubation, Outcome 3 Insertion time.
2.4
2.4. Analysis
Comparison 2 LMA versus endotracheal intubation, Outcome 4 Ventilation time [seconds].
2.5
2.5. Analysis
Comparison 2 LMA versus endotracheal intubation, Outcome 5 Apgar score ≤7 at 5 minutes.
2.6
2.6. Analysis
Comparison 2 LMA versus endotracheal intubation, Outcome 6 Soft tissue trauma after device inserted.
2.7
2.7. Analysis
Comparison 2 LMA versus endotracheal intubation, Outcome 7 Death or HIE.
See this image and copyright information in PMC

Update of

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