Chapter 37: Laryngeal Mask Airway

INTRODUCTION

The laryngeal mask airway (LMA) is an alternative airway device that consists of a soft elliptical mask with an inflatable cuff that is attached to a flexible airway tube. The mask covers the glottis (laryngeal opening), and the inflatable cuff occludes the esophagus. Placement of the LMA is feasible in neonates. A study shows it was successfully placed in <35 seconds in most patients with only 1 attempt with minimal fluctuations in heart rate and oxygen saturation (SaO₂). It is intended for use in babies who weigh >2000 g. The seventh edition of the American Academy of Pediatrics/American Heart Association Textbook of Neonatal Resuscitation states: “When you ‘can’t ventilate and can’t intubate,’ a laryngeal mask may provide a successful rescue airway.” The International Liaison Committee on Resuscitation and the European Resuscitation Council recommend that LMA can be used as an alternative to intubation with an ETT in late preterm, term, and infants >2000 g when face mask ventilation is unsuccessful or intubation is not possible. A recent Cochrane review (2018) states: The LMA can achieve effective ventilation during neonatal resuscitation in a time frame consistent with current guidelines. It is more effective than bag-mask ventilation in terms of shorter resuscitation and ventilation times, and less need for endotracheal intubation. Bansal et al in a critical review of the LMA in neonatal resuscitation suggests that the use of the LMA is a feasible and safe alternative to mask ventilation of late preterm and term infants in the DR, but state it is not recommended as initial respiratory support since evidence is still insufficient.

I. INDICATIONS

1. Ineffective face mask ventilation in neonates with:

   1. Abnormal facial anatomy (eg, cleft lip, cleft palate)

   2. Unstable cervical spine (eg, osteogenesis imperfecta, arthrogryposis, and trisomy 21)

   3. Upper airway obstruction (eg, Pierre-Robin sequence, micrognathia, large tongue, redundant tissues, and oral, pharyngeal, or neck tumors)

2. Rescue procedure after failed intubation or intubation not feasible.

3. Short-term mechanical ventilation for procedures in the neonatal intensive care unit.

4. Resuscitation in delivery room. Use of LMA was found to be a safe alternative to mask ventilation of late preterm and term infants in the delivery suite.

5. Administration of medications (controversial). Medications may leak from the mask and not enter the lungs. The seventh edition American Academy of Pediatrics/American Heart Association Textbook of Neonatal Resuscitation states: “There is insufficient evidence to recommend using a laryngeal mask to administer intratracheal medications.” Recent studies have shown that surfactant therapy through the LMA may be effective (results showed a decreased rate of intubation and mechanical ventilation in premature infants with RDS), but since there is not enough sufficient evidence it is not recommended for routine use.

6. Fiberoptic-guided intubation. LMA in infants undergoing minor elective procedures had clinically significantly fewer perioperative respiratory adverse events (PRAEs) and decreased incidence of major PRAEs than with endotracheal tubes.

II. EQUIPMENT

There are various ...