Supraglottic airways and neonatal resuscitation
Myron Yaster MD, Melissa Brooks Peterson MD, and Jayant K. Deshpande MD
I’m sure this has occurred to many, if not almost all of you. You arrive to the OR and find that you’ve been assigned a “learner” who is there to learn airway skills and earn their “merit badge” (I always fantasized about making a “sticker” with a cartoon laryngoscope that could ceremonially be awarded at the end of the day). Usually, the learner, who could be a pediatric resident or fellow, nurse practitioner, EMT, flight nurse or other “non-anesthesiologist.” These “visiting learners” arrive having learned the basics on “plastic” (at best) and want to become expert at intubation. You pause and think to yourself, “This is pretty f*cked up…it’s taken me years and literally thousands of patients to learn how to do this and to think these skills can be mastered in a day or two?!?”. Further, when you try to explain that the more important skill to learn first is mask ventilation and oxygenation rather than intubation you get a “death stare” and probably an anonymous report about your poor communication skills.
Further, even if you could teach these skills what is the retention rate and what will be remembered during an emergency, days, weeks, months, or years later? And what makes your learner an “expert”? For most skills it’s 50/year. Can this be achieved in the couple of days a visiting learner is assigned to you? I (MY) don’t think so. Nevertheless, you try because ventilation and oxygenation are one of the most important elements in resuscitation, particularly in pediatrics. As pediatric anesthesiologists, we hope for the best but prepare for the worst. What to do, what to do? Myron Yaster MD
Editorial
Stephen G Flynn, Mary Lyn Stein, John E Fiadjoe. Supraglottic Airways, Tennis, and Neonatal Resuscitation. Pediatrics. 2022 Sep 1;150(3):e2022057567. PMID: 35948629
Original article
Yamada NK, McKinlay CJ, Quek BH, Schmölzer GM, Wyckoff MH, Liley HG, Rabi Y, Weiner GM. Supraglottic Airways Compared With Face Masks for Neonatal Resuscitation: A Systematic Review. Pediatrics. 2022 Sep 1;150(3):e2022056568. PMID: 35948789
Today’s Pediatric Anesthesia article of the Day and its accompanying editorial is a systematic review and meta analysis of the use of supraglottic airways (SGA) compared to mask ventilation or intubation in neonatal resuscitation of infants > 34 weeks gestation. Cutting to the chase: SGA won hands down. “It was more successful at achieving successful resuscitation and increasing heart rate to > 100 beats/minute. There was no significant difference in other important and critical outcomes, including the probability of receiving chest compressions or epinephrine (adrenaline) during the initial resuscitation, admission to the NICU, air leak, soft tissue injury, admission to the NICU, or survival to hospital discharge”.[1]
Previous studies have shown that “that clinicians have difficulty delivering consistent tidal volumes or inflation pressures in manikin models and achieving chest expansion during actual resuscitations using a face mask”.[1, 2] Thus, the results of this study are similar to a previous recent Cochrane review and underscore the need to teach SGA insertion as a critical skill.[3] Experientially, we know that SGA placement is a skill that is easier to master than mask ventilation or laryngeal intubation. Thus, having SGAs in the delivery room makes a lot of sense because as the editorial emphasizes: “In scenarios in which seconds matter, infants in the SGA group got better faster”.[4] It is important to know what this metaanalysis defines as “clinicians” that were represented in this metaanalysis: anesthesiologists (not pediatric, 1/6), anesthesiology residents (1/6), midwives (3/6), pediatricians (2/6), generally listed “physicians” (2/6), and generally listed nurses (1/6). All of the represented studies report manikin training such as ACLS or neonatal resuscitation course; 4/6 studies this was the “preparation” for handling neonatal airways. Only 2/6 studies report “in vivo” practice – meaning, inserting any SGA in the OR (between 5-10 times total), and inserting an SGA in a neonate during resuscitation between 2-5 times. So, noting the relative inexperience of the airway operators in this study, we think it is a reasonable representation of our “visiting learner” population (as opposed to a study with pediatric anesthesiologists or even neonatologists as the clinician).
A weakness of this study, is that the article doesn’t define (or even discuss!) complications of SGAs, such as glottic trauma, gastric insufflation, and nerve injury. Nor does it review the various brands and types of SGAs or which ones to stock Another important limitation of this study is that it included only neonates > 34 weeks and didn’t include micro-premies in whom, as you all know, SGAs don’t work very well.
References
1. Yamada, N.K., et al., Supraglottic Airways Compared With Face Masks for Neonatal Resuscitation: A Systematic Review. Pediatrics, 2022. 150(3).
2. Finer, N.N., et al., Comparison of methods of bag and mask ventilation for neonatal resuscitation. Resuscitation, 2001. 49(3): p. 299-305.
3. Qureshi, M.J. and M. Kumar, Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation. Cochrane Database Syst Rev, 2018. 3(3): p. Cd003314.
4. Flynn, S.G., M.L. Stein, and J.E. Fiadjoe, Supraglottic Airways, Tennis, and Neonatal Resuscitation. Pediatrics, 2022. 150(3).