Laryngeal mask airway versus face mask ventilation or intubation for neonatal resuscitation in low-and-middle-income countries: a systematic review and meta-analysis

Abstract

ObjectiveTo assess whether laryngeal mask airway (LMA) as compared with face mask (FM) or endotracheal intubation (ETT) is more effective in delivering positive pressure ventilation (PPV) during neonatal resuscitation in low-and-middle income countries (LMICs).Study designWe followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and searched Medline (PubMed interphase), Cumulative Index of Nursing and Allied Health Literature, Embase and Cochrane Registry between January 1990 and April 2022 for the studies that examined the effect of LMA in delivering PPV compared with the FM or ETT in infants during neonatal resuscitation. We included the studies conducted in LMIC only. We assessed the quality of all the included studies using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) recommendations.ResultsOur search resulted in eight randomised studies Six studies compared LMA with FM and three studies compared LMA with ETT. When used as the primary device for providing PPV, the LMA as compared with FM resulted in a significant lower failure rate (relative risk (RR) 0.23, 95% CI 0.13 to 0.43) with moderate certainty of evidence (CoE) and lesser need for intubation (RR 0.21, 95% CI 0.07 to 0.58) with low CoE. There was no difference in the incidence of encephalopathy, neonatal admission, need for advanced resuscitations or death. No differences were observed between LMA and ETT. Studies comparing LMA to ETT were limited for any conceivable conclusion.ConclusionLMA is more effective than FM in delivering PPV with less failure rates and reduced need for intubation during neonatal resuscitation in term infants and in LMIC without any difference in the incidence of encephalopathy or death. Studies comparing LMA to ETT are scarce with important methodological limitations.PROSPERO registration numberCRD42021283478.

Time to Effective Ventilation in Neonatal Manikins with a Supraglottic Airway vs. a Facemask: A Randomized Controlled Trial

“…A 2018 Cochrane review evaluated five trials comparing the LMA to facemask ventilation and observed with low to moderate quality evidence that LMA use reduced intubation rates [ 6 ]. More recent systematic [ 15 ] and narrative [ 16 ] reviews reached similar conclusions after inclusion of Pejovic et al’s recent large trial [ 17 ], which included over 1100 neonates. In two other meta-analyses, it was similarly concluded that the use of supraglottic airways, including the LMA, in the neonatal population was associated with less failure of PPV than use of the facemask and subsequently decreased ETT requirements [ 15 , 16 ].…”

“…More recent systematic [ 15 ] and narrative [ 16 ] reviews reached similar conclusions after inclusion of Pejovic et al’s recent large trial [ 17 ], which included over 1100 neonates. In two other meta-analyses, it was similarly concluded that the use of supraglottic airways, including the LMA, in the neonatal population was associated with less failure of PPV than use of the facemask and subsequently decreased ETT requirements [ 15 , 16 ]. Diggikar et al additionally concluded that in low-to-middle income countries, there is no difference in death or moderate-to-severe hypoxic ischemic encephalopathy (HIE) in infants that were given PPV using a neonatal facemask or the LMA [ 15 ].…”

“…If PPV is ineffective despite corrective measures, it is recommended to then switch the ventilation interface to an endotracheal tube (ETT) or supraglottic airway such as the laryngeal mask airway (LMA). However, there is growing interest and evidence to support the use of the LMA as a first-line interface for PPV [ 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ].…”

“…In two other meta-analyses, it was similarly concluded that the use of supraglottic airways, including the LMA, in the neonatal population was associated with less failure of PPV than use of the facemask and subsequently decreased ETT requirements [ 15 , 16 ]. Diggikar et al additionally concluded that in low-to-middle income countries, there is no difference in death or moderate-to-severe hypoxic ischemic encephalopathy (HIE) in infants that were given PPV using a neonatal facemask or the LMA [ 15 ]. In a randomized controlled trial conducted in Uganda among experienced midwifes, there was no difference in the outcome of death within 7 days or admission to a neonatal intensive care unit (NICU) with moderate-to-severe HIE with the initial use of the LMA versus a facemask as the primary means of providing PPV [ 17 ].…”

Global Emergency Medicine: A Scoping Review of the Literature from 2022

“…A systematic review in Public Health by Najafi et al35 provided a broad overview of the increased incidence spinal cord injuries in LMICs found there is insufficient literature available to draw conclusions on best management practices and patient outcomes 46. Demonstrating that laryngeal mask airway was both safe and preferable to the use of traditional face mask for positive pressure ventilation during neonatal resuscitation in resource-limited settings, the systematic review and meta-analysis from Diggikar et al47 was both rigorous and supported by strict inclusion criteria. Elbaih et al48 showed that teaching a sequen-…”