Upload
chloe-horn
View
232
Download
0
Embed Size (px)
Citation preview
Dallas 2015
TFQO: Jeffry Pearlman COI# 187EVREV 1: Enrique Udaeta COI# 239EVREV 1: Edgardo Ezslyd COI# 277Taskforce: NRP
Laryngeal Mask Airway(NRP 618)
Dallas 2015COI Disclosure (NRP 618: LMA)
EVREV 1 COI # 239Commercial/industryâą No
Potential intellectual conflictsâą No
EVREV 2 COI # 277Commercial/industryâą No
Potential intellectual conflictsâą No
Dallas 2015
2010 Consensus on Science
In 1 randomized controlled trial (LOE 146) providers had similar success providing effective ventilation with either the laryngeal mask airway or face mask among newborns in the delivery room. In 1 retrospective cohort study (LOE 247) and 3 large case series (LOE 448) effective ventilation was achieved quickly using a laryngeal mask airway in newborns weighing >2000 g or delivered at â„34 weeks' gestation. In 1 randomized controlled trial (LOE 149) and 1 retrospective cohort study (LOE 250) providers had similar success providing effective ventilation using either the laryngeal mask airway or endotracheal tube among newborns in the delivery room. Although a single cohort study (LOE 250) suggests that newborns resuscitated with a laryngeal mask may require less respiratory support after initial resuscitation, this conclusion is subject to significant selection bias. In multiple small case reports effective ventilation was achieved with a laryngeal mask airway when both face mask ventilation and endotracheal intubation were unsuccessful. There is limited evidence to evaluate the effectiveness of the laryngeal mask airway for newborns weighing <2000 g, delivered at <34 weeks' gestation, in the setting of meconium-stained amniotic fluid, during chest compressions, or for administration of emergency intratracheal medications
Dallas 20152010 CoSTR
The laryngeal mask airway should be considered during resuscitation of the newborn if face mask ventilation is unsuccessful and tracheal intubation is unsuccessful or not feasible. The laryngeal mask airway may be considered as an alternative to a face mask for positive-pressure ventilation among newborns weighing >2000 g or delivered at â„34 weeks' gestation. There is limited evidence, however, to evaluate its use for newborns weighing <2000 g or delivered at <34 weeks' gestation. The laryngeal mask airway may be considered as an alternative to endotracheal intubation as a secondary airway for resuscitation among newborns weighing >2000 g or delivered at â„34 weeks' gestation. The laryngeal mask airway has not been evaluated in the setting of meconium-stained amniotic fluid, during chest compressions, or for administration of emergency intratracheal medications
Dallas 2015C2015 PICO
Population: In newborn infants at term that have indications for intermittent positive pressure for resuscitationIntervention: use of a laryngeal mask as a primary or secondary deviceComparison: endotracheal intubation or mask ventilation improve response to resuscitationOutcomes: Achieving stable vital signs (HR>100, respiratory effort, pink) 8-CriticalReducing the need for subsequent endotracheal intubation 8-CriticalIncreasing Apgar score 8-CriticalIndicators of neonatal brain injury (HIE, IVH) 9-Criticalneonatal morbidity (vomiting, gastric distension, reflux, injury) 5-Importantand mortality 9-Criticallong term outcomes (neurologic) 8-Critical
Dallas 2015
Inclusion/Exclusion/Articles Found
InclusionNewborns at term requiring PPV at birth using FM or ETT vs. LMA during neonatal resuscitation
ExclusionMajor malformations of the respiratory system or cyanotic congenital heart, need of chest compression, presence of meconium in amniotic fluid
Revised 721Embase 191, PubMed 378, Cochrane 52
âą Duplicated and removed 101âą Total 620
Included: 4 RCTs Excluded: 617 non RCT:
âą Case series, Review articles, Animal studies, Studies that did not specifically answer the question, Unpublished studies, Studies only published in abstract form
Dallas 2015
We suggest that the use of Laryngeal Mask Airway as a primary or secondary device for respiratory support in delivery room for newborns at term requiring positive pressure ventilation during neonatal resuscitation is feasible and safe, but there is not enough evidence to recommend it instead of Face Mask (weak recommendation from low quality of evidence for primary device, and weak recommendation from very low quality evidence as a secondary device).
2015 Proposed Treatment Recommendations
Dallas 20152015 Proposed Treatment Recommendations
There is limited evidence, however, to evaluate its use for premature infants. The laryngeal mask airway has not been evaluated in the setting of meconium-stained amniotic fluid, during chest compressions, or for administration of emergency intratracheal medications
The laryngeal mask airway should be considered during resuscitation of the newborn if face mask and/or endotracheal intubation is unsuccessful or not feasible.
Values and Preferences StatementsIn making these recommendations we place a moderate value in continuing using these device, but there is a necessity for more clinical trials.
Dallas 2015
Risk of Bias in studies
Dallas 2015
Article Weigth (g)
Age (weeks
)
Born LMAn
FMn
ETTn
Apgar
1-5
Apgar 10
Succ.Resc*
Esmail 2002Egypt*
>2500 (3,369)
>35 (38.8)
C-section
20 - 20 X X X
Singh 2005India*
>1500 (?)
>35(?)
C-section
25 25 - X X
Feroze 2008Pakistan*
>1500(?)
>35(?)
C-section
25 25 25 X X X
Zhu 2011China**
>2500(3,100)
>34(39.1)
C-section
76%
205 164 - X X
*Success resuscitation: not need for subsequent ET intubation
Dallas 2015Evidence profile table
Dallas 2015
1.1 Achieving vital signs (Success resuscitation)
1.2 Reducing need of subsequent endotracheal intubation
Dallas 2015Evidence profile table
Dallas 2015
LMA compared to FM as a primary device for infants at term requiring positive pressure ventilation for resuscitation (3 RCT with 469 patients)âąFor the critical outcome of âachieving vital signsâ we have identified low quality evidence from 2 small RCTs and 1 large Quasi RCT {Singh 2005, 303; Feroze 2008, 148; Zhu 2011, 1405}, showing that LMA was more effective than the FM (OR 11.43 95% CI 4.01- 32.58). âąFor the critical outcome of âneed for subsequent endotracheal intubation after failed LMA or FMâ, we have identified low quality evidence from the same RCTs, showing that LMA was more effective than the FM (OR 0.13 95% CI 0.05-34)âąFor the critical outcome of âApgar score increasingâ we have identified low quality evidence from the same RCTs, not being possible to analyze these outcome for the way of report in each study.
Proposed Consensus on Science statements
Dallas 2015
LMA compared to FM as a primary device for infants at term requiring positive pressure ventilation for resuscitation (3 RCT with 469 patients)âąFor the critical outcome of âdeadâ we have identified low quality evidence from the same RCTs, showing no difference between LMA or FM.âąFor the important outcome of âmorbidityâ we have identified low quality evidence from the same RCTs, showing no difference for any variable between LMA or FM (OR 5.76 95% IC 0.7 â 47.32). âąWe did not identify any evidence to address the critical outcomes of âindicators of brain injuryâ or âlong term outcomesâ
Proposed Consensus on Science statements
Dallas 2015
LMA compared to ETT as a secondary device for infants at term requiring positive pressure ventilation for resuscitation (1 RCT with 40 patients)For the critical outcome of âachieving vital signs or
successful resuscitationâ, we have identified very low quality evidence from one RCT {Esmail 2002, 115} showing that LMA was as effective as the ETT tube.
For the critical outcome of âneed for subsequent endotracheal intubation after failed LMAâ, we have identified very low quality evidence from the same RCT showing that LMA was as effective as ETT.
For the critical outcome of âApgar score increasingâ we have identified very low quality evidence from the same RCT, not being possible to analyze these outcome for the presentation of the results in the study.
Proposed Consensus on Science statements
Dallas 2015
LMA compared to ETT as a secondary device for infants at term requiring positive pressure ventilation for resuscitation (1 RCT with 40 patients)
For the critical outcome of âdeadâ we have identified very low quality evidence from the same RCT, showing no difference between LMA or FM or ETT.
For the important outcome of âmorbidityâ we have identified very low quality evidence from the same RCT, showing more trauma tissue comparing with LMA vs ETT (OR 2.43 (0.51 â 11.51).
We did not identify any evidence to address the critical outcome of indicators of brain injury or long term outcomes comparing LMA, FM or ETT as a secondary device.
Proposed Consensus on Science statements
Dallas 2015
We suggest that the use of Laryngeal Mask Airway as a primary or secondary device for respiratory support in delivery room for newborns at term requiring positive pressure ventilation during neonatal resuscitation is feasible and safe, but there is not enough evidence to recommend it instead of Face Mask as a primary device (weak recommendation from low quality of evidence), or as a secondary device (weak recommendation from very low quality evidence).
2015 Proposed Treatment Recommendations
Dallas 20152015 Proposed Treatment Recommendations
There is limited evidence, however, to evaluate its use for premature infants. The laryngeal mask airway has not been evaluated in the setting of meconium-stained amniotic fluid, during chest compressions, or for administration of emergency intratracheal medications
The laryngeal mask airway should be considered during resuscitation of the newborn if face mask and/or endotracheal intubation is unsuccessful or not feasible.
Values and Preferences Statements
In making these recommendations we place a moderate value in continuing using these device, but there is a necessity for more clinical trials especially for his use instead of endotracheal intubation.
Dallas 2015
Knowledge Gaps in LMA vs. FM vs ETT
The effectiveness and safety of LMA compared to mask ventilation as the primary interphase in term and preterm infants.The effectiveness of LMA compared to endotracheal intubation as a secondary deviceInsertion technique, which model, and how to teach its use.