24/01/2005
LARYNGEAL MASK AIRWAY FOR THE INTERHOSPITAL TRANSPORT OF NEONATES

The laryngeal mask airway has been established as a safe reliable tool in both adult and pediatric practice, in particular for airway control during interhospital transport of infants with congenital airway malformations.

The laryngeal mask airway (LMA) is an airway management device developed by Dr Archie Brain in 1981 and introduced into clinical practice for anesthesia and resuscitation of adult and pediatric patients. The device designed by Brain, modified and improved over the last 10 years, combines ease of insertion and adequate airway patency.
In particular, the LMA has proved to be useful for neonatal transportation if other forms of airway management fail. Airway control during interhospital transfer may present serious management difficulties, even for experienced personnel. In several case reports the LMA positioning has confirmed its ease of placement even by inexperienced personnel (Pediatrics 2005; 115: e109-111 Full Text)

In situations of severe congenital airway malformation of the infant, the LMA allows effective ventilation and oxygenation, as its insertion technique, stable positioning and function is not influenced by anatomical factors. The LMA use is determined by the failure of conventional modes of ventilation (facial mask and tracheal intubation), which may be also caused by congenital airway abnormalities of the infant. Furthermore, in comparison with the face mask, positive pressure ventilation (PPV) is achieved and maintained with the LMA requiring less skill.

Because of its ease of placement and its relative long acceptance by the patients - in 3 of 5 cases no sedative and/or paralytic drugs were used, the LMA may play an important role in airway management in all phases of the transport process, even during helicopter transportation.

Advantages of the LMA over the face mask
By developing the LMA manipulation of the patient’s head, neck, and jaw is not required and compression of facial nerves is avoided. The LMA enhances a better airtight seal, providing more effective PPV. A meta-analysis (Brimacombe J. Can J Anaesth 1995; 42(11): 1017 PubMed) including 52 randomised prospective trials reported that the advantages of the LMA over the face mask included:

• easier placement by inexperienced personnel
• improved oxygen saturation
• less hand fatigue
• improved operating conditions during minor pediatric otological surgery.

Advantages of the LMA over endotracheal intubation
The LMA avoids laryngoscopy and all of its related adverse effects and with respect to the respiratory tract it is also less invasive. LMA positioning and removal involve a lower haemodynamic stress response by the patient, and this could theoretically reduce the incidence of cerebral haemorrhage in neonates. Furthermore the LMA use avoids tracheal oedema, which on the contrary may be caused by tracheal intubation. The advantages of the LMA over the tracheal tube also include increased speed and ease of placement by both anaesthetists and trained non-medical personnel.

Official Scientific Societies, such as the American Academy of Pediatrics, suggested that the LMA may represent an effective alternative for maintaining a patent airway if bag-mask ventilation is ineffective or intubation fails.
In addition the feasibility of administering surfactant using the LMA has been studied in eight preterm infants with respiratory distress syndrome (Arch Dis Child Fetal Neonatal Ed. 2004; 89(6): F485-9. PubMed). The data gained indicate that a rapid and non-invasive access to the trachea of preterm infants can be obtained by using the LMA as a conduit to administer surfactant.

Although the LMA cannot be considered as a routine substitute for the tracheal tube, and further studies are required to compare all of its advantages and limits with conventional devices currently used, features of more recent LMA versions highlight potential optimal conditions for use in neonatal patients.

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