Neonatal HLR - har larynxmask någon plats? Linda Wallström Barnläkare/Neonatolog Intensivvårdsavdelning för nyfödda avd 95F Akademiska barnsjukhuset

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1 Neonatal HLR - har larynxmask någon plats? Linda Wallström Barnläkare/Neonatolog Intensivvårdsavdelning för nyfödda avd 95F Akademiska barnsjukhuset

2 Svara på frågan Aktuella riktlinjer LMA från ett större perspektiv Ventilation

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5 ILCOR/ERC 2020 Evidensbaserade rekommendationer Internationell konsensus

6 Laryngeal mask airway LMA can be used in resuscitation of the newborn, particulary if facemask ventilation is unsuccessful or tracheal intubation is unsuccessful or not feasible. The LMA may be considered as an alternative to facemask for positive pressure ventilation among newborns weighing >2000 g or delivered 34 weeks gestation.

7 Alternativ till maskventilation? LMA achieve effective PPV (range 95-99% in several studies) LMA reduce need for ETT Easy to apply Pejovic et al. Neonatal resuscitation using a laryngeal mask airway: a randomised trial in Uganda. Arch Dis Child March.103(3) (bild ovan från artikel)

8 Alternativ till intubation?..may be an alternative..is recommended in term neonates if intubation unsuccessful or not feasible Few RCT studies

9 Study Design Main Outcomes Conclusion Paterson et al(1994) Observational(21) In all 20 newborns LMA was successfully inserted One patient LMA was exchanged to ETT LMA effective in providing PPV at birth and easily learned by personel familiar with neonatal resuscitation Gandini and Brimacombe (1999) Observational (104) Meconium aspiration excluded 103(99%) infants were successfully resuscitated. Low BW requires longer PPV. LMA can be used in normal BW and low BW neonates Trevisaanuto et al (2004) Observational. (95) LMA effective in 99%. Infants requiring ETT reduced 67% compared to 34% Between groups (74-74) no difference in Apgar, need for intubation, need for NICU admission. LMA safe and useful alternative method for respiratory support Zanardo Observational(43) CS. Control group vaginal delivery(18) 70% use LMA. Successful in 42/43 (one LMA exchanged to ETT). Lower probability to have low Apgar at 1 and 5 min, NICU adm and IMV. LMA insertion was not associated with any adverse neg effeccts Zanardo(2010) Observational. Retroperspective(36) 5 years Clinical chose FM, LMA, or ETT LMA(41.8%), FM (39.5%), ETT (18.6%). Resuscitation with LMA associated with lower rate NICU admission, shorter LOS. LMA is effective as a primary airway management

10 Study Design(n/n) Comparison Main outcomes Esmail et al (2002) RCT(20/20) LMA vs. ETT Success with LMA and ETT might be similar if FM has failed. Singh et al (2005) RCT(25/25) LMA vs. FM LMA group higher rate success in ventilation (96 vs. 88%) Same Apgar, similar rate of ETT Feroze et al (2008) RCT(25/25/25) ETT vs FM vs LMA % No difference insertion time. How many excluded? Randomization process? BW >1500 g Zhu et al(2011) RCT(205/164) LMA vs. FM Less ETT, shorter MV times SIB and FM Trevisanuto et al (2015) RCT(71/71) LMA vs. FM Success rate of resuscitation( 91.5 vs. 78.9%), and in BW g(n=37) 86.7 vs. 59.1% Lower rate of NICU admission Yang et al (2016) RCT(36/32) LMA vs. ETT Start FM. No difference in successful resuscitation, insertion time, response time, ventilation time Pejovic et al (2017) RCT(24/25) LMA vs. FM Shorter time to spontaneous breathing(153 s vs. 216 s). LMA safe and effective in clinical short training programme BW >1500 g igel

11 Side effects/adverse events LMA Soft tissue trauma Vomiting/regurgitation Stridor/Airway obstruction

12 Study Type of trauma Comment Long term complications Esmail et al (2002) Soft tissue trauma epiglottis and uvula 2 treated with steroids None Zhu et al(2011) A few cases of vomiting/regurgitation Only in patient Apgar 7 Trevisanuto et al (2015) None Pejovic et al (2017) None Paterson et al(1994) None Gandini and Brimacombe (1999) None (Blood in oropharynx?) Zanardo et al (2010) None Trevisanuto et al (2011) Upper esophageal lesion Case report. Extremely low birth weight LMA n 1, cuffed.

13 Primary airway device Secondary airway device LMA -summary LMA has not been evaluated for infants with meconiumstained fluid, during chest compressions Compared to ETT adverse events, longterm outcome Whether LMA insertion in newborns is an easier skill to acquire compared to endotracheal intubation insertion. < 1.5 (2 kg)

14 Ventilation-färdighetsträning Fri luftväg Ventilationsteknik Kunskap om utrustning Träna ofta och regelbundet Hjälpmedel

15 Intubationsträning Real life opportunities limited ncpap No routine endotracheal suction

16 Intubation O Donell, Morley CJ et al. Pediatrics Endotracheal intubation attempts during neonatal resuscitation: success rates, duration, and adverse effects

17 Situation awarenesssituationsmedvetenhet Kunskap om egna situationen

18 Färdighetsträning Hur ser det ut Hur ofta Hur ser personalomsättning ut Utrustning Hur ser mängden akuta situationer ut på enheten Vilka akuta situationer har ni på er enhet

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20 Practice - the only way Rutiner Färdighetsträning Simulering Timeout Återkoppling Neonatal HLR är ett teamarbete -tillkalla behövlig hjälp tidigt Bild från neohlrutbildning.se

21 Framtiden? Ventilation: Nasal prongs LMA Mätutrustning med kontinuerlig feedback Teamanpassade riktlinjer

22 Take home message Ventilationsträna! Maskventilation är fortfarande grunden i ventilation av det nyfödda barnet I färdighetsträning av luftvägshantering ingår LMA LMA vid svår luftväg/missbildning? LMA om behov vid transport?