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

  • Review
  • Intervention

Authors

  • Andrew J. Grein,

    Corresponding author
    1. Riley Hospital for Children, Pediatrics, Section of Neonatology, Indianapolis, Indiana, USA
    • Andrew J. Grein, Pediatrics, Section of Neonatology, Riley Hospital for Children, 699 West Drive, RR 208, Indianapolis, Indiana, 46202, USA. ajgrein@iupui.edu.

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  • Gary M Weiner

    1. Riley Hospital for Children, Pediatrics, Section of Neonatology, Indianapolis, Indiana, USA
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Abstract

Background

Providing effective positive pressure ventilation is the single most important component of successful neonatal resuscitation. Ventilation is frequently initiated with a manual resuscitation bag and face-mask (BMV) followed by endotracheal intubation (ETT) if depression continues. These techniques may be difficult to perform successfully resulting in prolonged resuscitation or severe neonatal depression. 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 resuscitation, is effective ventilation and successful resuscitation achieved faster with the LMA compared with either BMV or ETT?

Search methods

The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), MEDLINE (1966-November 2004), Pre-MEDLINE (November 15, 2004), CINAHL 1982-November 2004), reference lists of published trials, and Society for Pediatric Research abstracts were searched. Experts were contacted for additional references.

Selection criteria

Randomised and quasi-randomised trials

Data collection and analysis

Two reviewers independently evaluated studies, assessed methodologic quality, and extracted data using the Cochrane Neonatal Review Group criteria. Categorical treatment effects were described as relative risks and risk differences and continuous treatment effects were described as the mean difference. There were insufficient data to perform pooled analyses.

Main results

No eligible studies compared the LMA with BMV. One small randomised controlled trial comparing the LMA with ETT when BMV had been unsuccessful was included. There was no statistically significant difference between the LMA and ETT with the exception of a clinically insignificant difference in time to complete insertion of the device favouring the ETT.

Authors' conclusions

The LMA can achieve effective ventilation during neonatal resuscitation in a time-frame consistent with current guidelines. There is no evidence to evaluate the relative efficacy and safety of the LMA compared with BMV as the primary airway device. A single, small randomised controlled trial found no clinically significant difference between the LMA and ETT when BMV was unsuccessful. Case series and case reports suggest that the LMA can provide an effective rescue airway during resuscitation if both BMV and ETT have been unsuccessful. A well-designed randomised controlled trial comparing the LMA with BMV during neonatal resuscitation is warranted.

摘要

背景

新生兒復甦急救時使用喉頭罩呼吸道(laryngeal mask airway)和面罩甦醒球通氣(bagmask ventilation)或是氣管插管之比較

提供有效的正壓呼吸是新生兒復甦急救能成功的最重要元素,通常維持呼吸是先手壓面罩甦醒球(bagmask ventilation, BMV),使用BMV無效就會接著採用氣管插管(endotracheal intubation, ETT),但這些技術可能難以成功,而造成持續過久地復甦急救或是嚴重的新生兒窘迫。喉頭罩呼吸道(laryngeal mask airway, LMA)可能可以提供比BMV或是插管更迅速有效的復甦急救成功。

目標

在需要使用正壓呼吸復甦的新生兒中,究竟使用LMA會不會比BMV或是插管較快能達到有效且成功的結果?

搜尋策略

搜尋範圍包括Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004)、MEDLINE (1966–November 2004)、PreMEDLINE (November 15, 2004)、CINAHL(1982–November 2004)、已出版研究之參考文獻和Society for Pediatric Research的摘要。另外也跟專家接觸尋求額外的其他參考文獻。

選擇標準

隨機和準隨機試驗。

資料收集與分析

兩位專家分別評估研究的內容、方法品質,用Cochrane Neonatal Review Group 標準來取得資料。治療效果的項目以relative risks 和risk differences來表示,治療效果的連續性變數以mean difference來描述;沒有足夠的數據來進行pooled analyses 。

主要結論

沒有比較喉頭罩和面罩甦醒球的合適研究,找到一篇小型隨機研究比較當面罩甦醒球沒有效果時喉頭罩和採用氣管插管兩者。喉頭罩和氣管插管之間沒有統計學上顯著的差異,除了插管完成的時間稍快一些,但並無明顯差異。

作者結論

喉頭罩可以符合現行新生兒急救的時間限制,至今沒有證據來評量第一線建立氣道方式是喉頭罩還是面罩甦醒球較有效和安全。一篇小型隨機研究比較當面罩甦醒球沒有效果時喉頭罩和氣管插管兩者,它們之間沒有臨床上顯著的差異。有個案系列和個案報告指出喉頭罩在面罩甦醒球和氣管插管兩者皆無效時,可以建立有效的氣道。建議進行一個設計良好的隨機臨床試驗,比較在新生兒復甦時使用喉頭罩還是面罩甦醒球好。

翻譯人

本摘要由馬偕醫院蕭玥玲翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

新生兒復甦器材包含喉頭罩、面罩或是氣管插管。多數的新生兒在出生時都是很有活力的,但有少數在產房需要呼吸上的輔助。剛出生的嬰兒若是沒有有效的呼吸很快會呼吸窘迫,所以快速提供有效的換氣是十分重要的。通常都是先採用擠壓連接氧氣的甦醒球經由蓋住嬰兒口鼻的面罩給予氧氣,若是呼吸仍是衰竭就會直接將一根管子插入大的呼吸道\(氣管插管)。但是當嬰兒有呼吸道阻塞或是頭部和臉部異常時,使用面罩甦醒球或是氣管插管可能會有困難,這是因經由鼻孔和口腔進入肺部的正常氣流受到阻塞,並且當醫療人員試圖插管時氣道的視野受阻所致。喉頭罩是一種替代面罩甦醒球通氣和氣管插管的方式,乃是一個小罩子接到矽膠管末端,其大小正好吻合喉部,並可以直接給予正壓呼吸。此篇回顧的作者從徹底地醫學文獻搜尋中,找到了一篇40個嬰兒的小型隨機研究比較當面罩甦醒球沒有效果時,喉頭罩和氣管插管兩者,它們之間沒有臨床上的差別;兩者急救者都可以十分快速的插入(7.5–10秒),而且有很高的第一次成功率。仍沒有比較喉頭罩和面罩甦醒球的隨機研究。

Plain language summary

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

Using a laryngeal mask, a face mask or a tube directly into the large breathing passage (endotracheal intubation) for resuscitation of a newborn infants. Most newborns are vigorous at birth, but a small number need to be helped with breathing (assisted ventilation) in the delivery room. If infants do not have effective breathing soon after birth, they can
become severely depressed, so rapidly providing effective ventilation in the delivery room is very important. Ventilation is often started using a bag with oxygen attached, that is manually pumped (manual resuscitation bag) to force air into a close-fitting face mask held over the infant's nose and mouth. If breathing remains depressed after using the manual resuscitation bag, a tube is placed directly into the infant's large airway (endotracheal intubation). Bag and mask ventilation and endotracheal intubation may not be possible when infants have airway obstructions or head and face abnormalities, obstructing the normal flow of air through the nose and mouth into the lungs and obstructing the view of the airway by the medical personnel attempting intubation. The laryngeal mask airway is an alternative to bag and mask ventilation and endotracheal intubation that uses a small mask attached to the end of a silicone tube, which can be fitted into the throat to provide positive pressure ventilation into the airway. The review authors made a thorough search of the medical literature and found one, small randomized trial (with 40 infants) that compared the laryngeal mask with endotracheal intubation, when bag and mask ventilation had been unsuccessful. There was no clinical difference between the two methods. Overall, the time taken to insert both devices was very short (7.5 to 10 sec) and the resuscitators had a very high first time success rate. No eligible randomized studies compared the laryngeal mask with bag and mask ventilation.