What is the role of a Laryngeal Mask Airway (LMA) in neonatal resuscitation, particularly in premature or complicated newborns?

Laryngeal Mask Airway in Neonatal Resuscitation

The LMA is recommended as a lifesaving alternative when endotracheal intubation is unsuccessful or not feasible in late-preterm and term newborns (≥34 weeks gestation), and may be considered as an alternative to face-mask ventilation when bag-mask ventilation fails. 1

Gestational Age and Weight Restrictions

Critical limitation: LMA use is only supported for infants ≥34 weeks gestation or weighing >2000 g. 1

• Evidence is insufficient for premature infants <34 weeks gestation or <1500 g birth weight 2, 3
• All major trials excluded very preterm infants, creating a significant knowledge gap 1, 2

Primary Indications and Positioning in Resuscitation Algorithm

As a Secondary Device (Strongest Recommendation)

When face-mask ventilation fails or endotracheal intubation is unsuccessful/not feasible, use LMA immediately (strong recommendation, good clinical practice). 1

• LMA is as effective as endotracheal intubation for achieving stable vital signs when bag-mask ventilation has failed 1
• No difference in mortality compared to endotracheal tube as rescue device 1
• This represents the most evidence-based and clinically appropriate use of LMA 1

As a Primary Device (Weaker Recommendation)

LMA may be used instead of face-mask ventilation as the initial ventilation device, though this is a weaker recommendation (weak recommendation, low-quality evidence). 1

Evidence supporting primary use: 1

• More effective than face mask for achieving vital signs (OR 11.43,95% CI 4.01-32.58)
• Reduces need for subsequent endotracheal intubation by 87% compared to face mask (OR 0.13,95% CI 0.05-0.34)
• Shorter ventilation times (18.9 seconds less than bag-mask) 3
• Lower NICU admission rates (RR 0.60,95% CI 0.40-0.90) 3

Important caveat: Over 80% of infants in trials responded to bag-mask ventilation alone, suggesting LMA should be reserved for rescue rather than routine primary use 3

Clinical Effectiveness Compared to Other Devices

LMA vs Face Mask

• Superior for: Achieving stable vital signs, reducing intubation need, shorter resuscitation times 1
• No difference in: Gastric distention or vomiting (OR 5.76,95% CI 0.7-47.32) 1
• Quality of evidence: Low (downgraded for very serious risk of bias) 1

LMA vs Endotracheal Tube

• Equivalent for: Achieving vital signs, successful resuscitation, mortality 1
• Comparable insertion times with no clinically significant differences in failure rates (RR 0.95% CI 0.17-5.42) 3
• Potential concern: Slightly more tissue trauma (OR 2.43,95% CI 0.51-11.51), though evidence is very low quality 1
• Quality of evidence: Very low (downgraded for imprecision and risk of bias) 1

Practical Implementation

Success rate: LMA was successfully inserted on first attempt in all cases in early studies, with 20/21 neonates successfully resuscitated 4

Key advantage: Can be used effectively by personnel with less intubation expertise, addressing the challenge that endotracheal intubation is the most difficult skill to learn in neonatal resuscitation 1

Critical Limitations and Contraindications

Absolute limitations where LMA has NOT been evaluated: 1

• During chest compressions
• For administration of emergency medications (e.g., epinephrine)
• Infants <34 weeks gestation or <2000 g

Evidence gaps: 1

• No data on brain injury indicators or long-term neurologic outcomes
• Insufficient evidence for congenital diaphragmatic hernia or other special circumstances requiring intubation

Barriers to Implementation

Major barriers identified in 2024 European survey: 5

• 26% of delivery rooms not equipped with LMA
• Only 6% of healthcare providers received LMA-specific training
• Lack of confidence is the primary barrier to implementation
• Providers feel less competent with LMA compared to face mask or endotracheal tube

Solutions: 5

• Increase LMA availability in delivery wards
• Implement structured training programs
• Provide expert supervision during clinical practice

Recommended Clinical Approach

For late-preterm and term infants (≥34 weeks) requiring positive pressure ventilation:

1. First-line: Attempt bag-mask ventilation
2. If bag-mask fails: Insert LMA immediately rather than attempting multiple intubation attempts
3. If LMA unavailable or fails AND intubation not feasible: This represents a critical airway emergency requiring immediate advanced support

Do not delay LMA insertion when bag-mask ventilation is ineffective—proactive use prevents prolonged hypoxia and avoids unnecessary intubation attempts 3