Massimo Micaglio

Laryngeal Mask Airway Used as a Delivery Conduit for the Administration of Surfactant to Preterm Infants with Respiratory Distress Syndrome

Background: The laryngeal mask airway (LMATM, Laryngeal Mask Co. Ltd, Jersey, UK) is a supraglottic device used to administer positive pressure ventilation (PPV) in adults, pediatric and neonatal patients. Objectives: To avoid endotracheal intubation, we evaluated the feasibility and practicality of administering surfactant via the LMATM in preterm infants with respiratory distress syndrome (RDS). Methods: Infants less than 72 h old with a gestational age of ≤35 weeks and a birth weight of >800 g, treated with nasal continuous positive airway pressure (CPAP, 5 cm H2O) for RDS were eligible for inclusion in the study if the arterial-to-alveolar oxygen tension ratio (a/APO2) was <0.20 over a period of >60 min. Results: Eight preterm infants, median gestational age 31 (range 28–35) weeks; birth weight 1,700 (880–2,520) g, treated with nasal CPAP for RDS were enrolled. Three hours after surfactant instillation, the mean a/APO2 was significantly increased (0.13 ± 0.04 to 0.34 ± 0.11; p < 0.01) without complications. Conclusions: The LMATM may be a useful and noninvasive conduit for the administration of surfactant therapy. A large randomized comparative clinical trial will be required to confirm the efficacy of this technique.

Delivery room resuscitation of near-term infants: Role of the laryngeal mask airway

AIM This observational study aims to describe: (1) the use of positive pressure ventilation (PPV) for resuscitation in the delivery room among newly born near-term infants; (2) the methods used for PPV resuscitation [e.g., bag-facial mask (BFM), laryngeal mask airway (LMA), endotracheal tube (ETT)]; and (3) the association of each device with short-term neonatal outcomes. METHODS We identified near-term (34 0/7-36 6/7 weeks) infants delivered at the Padua University Hospital (Padua, Italy) during the years 2002-2006. The mode of delivery, gestational age, birth weight, Apgar scores, methods of resuscitation and respiratory outcome after NICU admission were analysed. RESULTS During the 5-year study period, 921 (4.9%) near-term infants were identified from a total of 18,641 live births. PPV was provided in the delivery room to 86 (9.3%) of these infants. Among them, 36 (41.8%) were managed by LMA, 34 (39.5%) by BFM and 16 (18.6%) by ETT. Thirty-four (39.5%) resuscitated near-term infants were admitted to the Neonatal Intensive Care Unit (NICU): 15 (44.1%) after BFM, 12 (75%) after ETT and seven (19.4%) after LMA. Resuscitation with an ETT was associated with an increased rate of respiratory distress syndrome when compared with either BFM or LMA. Resuscitation with an LMA was associated with a lower rate of NICU admission and shorter length of stay when compared with either BFM or ETT. CONCLUSION The LMA is an effective device for primary airway management of near-term infants and for secondary airway management among near-term infants failing BFM or ETT resuscitation.

Supreme Laryngeal Mask Airway versus Face Mask during Neonatal Resuscitation: A Randomized Controlled Trial

OBJECTIVE To assess the effectiveness of supreme laryngeal mask airway (SLMA) over face mask ventilation for preventing need for endotracheal intubation at birth. STUDY DESIGN We report a prospective, randomized, parallel 1:1, unblinded, controlled trial. After a short-term educational intervention on SLMA use, infants ≥34-week gestation and/or expected birth weight ≥1500 g requiring positive pressure ventilation (PPV) at birth were randomized to resuscitation by SLMA or face mask. The primary outcome was the success rate of the resuscitation devices (SLMA or face mask) defined as the achievement of an effective PPV preventing the need for endotracheal intubation. RESULTS We enrolled 142 patients (71 in SLMA and 71 in face mask group, respectively). Successful resuscitation rate was significantly higher with the SLMA compared with face mask ventilation (91.5% vs 78.9%; P = .03). Apgar score at 5 minutes was significantly higher in SLMA than in face mask group (P = .02). Neonatal intensive care unit admission rate was significantly lower in SLMA than in face mask group (P = .02). No complications related to the procedure occurred. CONCLUSIONS In newborns with gestational age ≥34 weeks and/or expected birth weight ≥1500 g needing PPV at birth, the SLMA is more effective than face mask to prevent endotracheal intubation. The SLMA is effective in clinical practice after a short-term educational intervention. TRIAL REGISTRATION Registered with ClinicalTrials.gov: NCT01963936.

Neonatal Resuscitation by Laryngeal Mask Airway after Elective Cesarean Section

The aim of this case-control study was to determine whether unplanned resuscitation using a laryngeal mask airway (LMA) is suitable for neonates delivered by elective cesarean section, a procedure known to carry a risk of inadequate physiological response to birth with a consequent adverse respiratory outcome. During a 3-year period, from January 1998 to December 2000, all newborns delivered by elective cesarean section at term were compared with the next infant born vaginally in the same maternity unit (level III center). The two groups were matched for gestational age >37 weeks. The requirement for resuscitation with positive-pressure ventilation (PPV) using either the LMA or an endotracheal tube (ETT), together with the occurrence of an adverse neonatal outcome, was recorded and analyzed in the cesarean section and vaginal delivery groups. During this time 1,284 at-term elective cesarean sections were performed. 3% (n = 43) of the cesarean section deliveries and 1.4% (n = 18) of the vaginal controls required PPV resuscitation by LMA or ETT, a significant difference (OR 1.26; 95% CI 2.38–5.1; p < 0.01). Of the cesarean section group requiring resuscitation, 30 neonates were managed with the LMA and 13 with the ETT, while in the control vaginal delivery group the numbers were 13 and 5, respectively. LMA use accounted of about 70% of the overall PPV resuscitations and was associated with a successful outcome in 42 of 43 cases. One case was unsuccessfully managed with the LMA, and the ETT subsequently used was effective. Moreover, the probability for the LMA-resuscitated newborns of both cesarean and vaginal groups to have a <5 Apgar score at 1 and 5 min, neonatal intensive care unit admission, and respiratory insufficiency requiring oxygen and intermittent mandatory ventilation was statistically lower than for the ETT group (p < 0.01). In conclusion, infants born by elective cesarean section at term are at increased risk of requiring PPV resuscitation as compared with those born by vaginal delivery. We have shown that about 70% of the neonates who required PPV resuscitation after elective cesarean section and vaginal delivery were arbitrarily treated with LMA by the attending anesthesiologist, without adverse negative respiratory outcome.

Training for neonatal resuscitation with the laryngeal mask airway: a comparison of the LMA-ProSeal and the LMA-Classic in an airway management manikin.

Background : Neonatal resuscitation is a mandatory skill for healthcare professionals involved in maternity suites. For ethical reasons, it is impossible to teach and practice airway management skills on neonates, and manikins are used for this purpose. The Classic Laryngeal Mask Airway TM (cLMA) is accepted as an effective device for airway management during neonatal resuscitation. A neonatal size of the LMA‐ProSealTM (PLMA) was recently produced, but there are no comparative data on its performance. We describe the comparison of the performances of the neonatal cLMA and the neonatal PLMA when used by different healthcare professionals in a dedicated airway management manikin.

Laryngeal Mask Airway for neonatal resuscitation in a developing country: evaluation of an educational intervention. Neonatal LMA: an educational intervention in DRC

BackgroundStudies carried out in developing countries have indicated that training courses in newborn resuscitation are efficacious in teaching local birth attendants how to properly utilize simple resuscitation devices. The aim of this study was to assess the knowledge and expertise gained by physicians and midwifes who participated in a Neonatal Resuscitation Course and workshop organized in a Third World Country on the use of Laryngeal Mask Airway (LMA).MethodsA 28-item questionnaire, derived from the standard test contained in the American Heart Association and the American Academy of Pediatrics Neonatal Resuscitation Manual, was administered to 21 physicians and 7 midwifes before and after a course, which included a practical, hands-on workshop focusing on LMA positioning and bag-ventilation in a neonatal manikin.ResultsThe knowledge gained by the physicians was superior to that demonstrated by the midwifes. The physicians, in fact, demonstrated a significant improvement with respect to their pre-course knowledge. Both the physicians and the midwives showed a good level of expertise in manipulating the manipulating the manikin during the practical trial session. The midwifes and physicians almost unanimously manifested a high degree of approval of neonatal resuscitation by LMA, as they defined it a sustainable and cost-effective method requiring minimal expertise.ConclusionsFurther studies are warranted to test the advantages and limits of the neonatal LMA training courses in developing countries.

Feasibility of nitric oxide administration by neonatal helmet‐CPAP: a bench study

Background:  Inhaled nitric oxide (NO) may have a role in the treatment of preterm infants with respiratory failure. We evaluated the feasibility of administering NO therapy by a new continuous positive airway pressure (CPAP) system (neonatal helmet‐CPAP).

Use of the LMA CTrach™ in unexpected difficult airway : a case report

© 2006 Copyright European Society of Anaesthesiology, European Journal of Anaesthesiology 23: 440–448 EDITOR: The intubating laryngeal mask airway (ILMA) (LMA FastrachTM, Laryngeal Mask Company, Cyprus) is a modified laryngeal mask airway (LMA) designed by Brain in 1997 to facilitate blind intubation with a tracheal tube [1,2]. The new LMA CTrachTM (CTrach) (The Laryngeal Mask Company Limited, UK) is a further development of the LMA FastrachTM. It has a very similar design but is provided with a built-in viewing system which allows fibreoptic visualization of the larynx through a modified epiglottic elevating bar before and during passage of the tracheal tube through the vocal cords (Fig. 1). We report a preliminary case of unexpectedly difficult intubation in which the new device was used.

Pulmonary hypertension during pregnancy: management of two cases

PurposeThe aim of this article is to describe two cases of pulmonary hypertension during pregnancy to highlight the major issues associated with the obstetric and anesthesiological management of such patients who, despite the medical advice, decided to continue their pregnancy and gave birth to healthy babies.Methods and resultsIn our first case, there has been the need for a general anesthesia because of the detachment of the placenta, whereas in the second case elective surgery under spinal anesthesia was performed, thus avoiding the anesthesiological and surgical problems associated with an emergency.ConclusionsPregnancy is contraindicated in case of pulmonary hypertension, a highly morbid disease affecting young women of childbearing age. Therefore, in such cases, a multidisciplinary approach is indispensable to plan optimal treatment for patients who wish to pursue a pregnancy even though their heart disease exposes them to a high level of risk.

Three different approaches to fibreoptic-guided intubation via the Laryngeal Mask Airway Supreme

tube does not allow the use of an ETT for a direct fiberoptic scope (FOS) exchange. The cuff has symmetrical fins on the side of the drain tube; directing the Aintree catheter (Cook Critical Care, Bloomington, IN) through the fins or the FOS above the fins is cumbersome [2]. The components of the Arndt airway exchange catheter set (Cook Critical Care) are: a bronchoscopic port, a wire guide, a radiopaque exchange catheter, and a rap-fit adapter. The technique applied is as follows: with the FOS in situ, the wire is inserted through the working port. Under direct visualization in the trachea, the wire is then exchanged to an airway exchange catheter (AEC) and ultimately after removing the LMA Supreme â the AEC is exchanged for an ETT. The LMA Supreme accommodates, under the fin, both the pediatric FOS (Fig. 1) and the AEC provided in the kit (Fig. 2). The technique used by Mathes et al. has two limitations: the authors had to reposition the LMA Supreme (â Chandi maneuverâ ) to advance the AEC into the trachea and, in two of the 4 patients, the AEC was advanced dorsally into the esophagus. With the Arndt AEC set, the AEC tracheal advancement is wire-guided (Seldinger technique) and unchallenging. In my clinical experience (three cases), there were no complications with the Arndt AEC set. A limitation of this technique may be the three steps involved: FOS to wire, wire to AEC, and AEC to ETT. This limitation is mitigated by the use of the bronchoscopic port and oxygenation of the patient during the procedure. An essential part of a new SGA device evaluation considered for routine and emergency use is the FOS glottic view and the ability to exchange the SGA with an ETT (â dedicated airwayâ ) [3]. Most practitioners are familiar with the Classic LMA glottic view and the ability to use the Aintree catheter. The new SGA devices on the market may have specific features that may impact on the routine exchange to an ETT. Adrian A. Matioc MD (Clinical Associate Professor) University of Wisconsin Hospital and Clinics Anesthesiology Service William S. Middleton Memorial Veterans Hospital Madison, WI E-mail address: adrian.matioc@va.gov