Airway Management In Neonates – Help From The Cochrane Library

Here are two resources I came across on neonatal resuscitation from Cochrane Database of Systematic Reviews while researching another aspect of airway management (in adults).

The authors of Resource (1) below concluded:

Current available evidence suggests that use of a stylet during neonatal orotracheal intubation does not significantly improve the success rate among paediatric trainees. However, only one brand of stylet and one brand of endotracheal tube have been tested, and researchers performed all intubations on infants in a hospital setting. Therefore, our results cannot be generalised beyond these limitations.

The authors note that in the single study available for review “Study authors did not report neonatal morbidity nor mortality.” With that in mind, I will not be using a stylet in my upcoming Neonatal Resusctation Course recertification. [Although I’ve attended many births as the neonatal resuscitator, I’ve never needed to entubate a newborn. But my plan has always been to use only the endotracheal tube as I worry about the stylet causing damage in the high stress situation of neonatal resuscitation.

The authors of Resource (2) below concluded:

LMA can achieve effective ventilation during neonatal resuscitation in a time frame consistent with current neonatal resuscitation guidelines. Compared to BMV, LMA is more effective in terms of shorter resuscitation and ventilation times, and less need for endotracheal intubation (low- to moderate-quality evidence). However, in trials comparing LMA with BMV, over 80% of infants in both trial arms responded to the allocated intervention. In studies that allowed LMA rescue of infants failing with BMV, it was possible to avoid intubation in the majority. It is important that the clinical community resorts to the use of LMA more proactively to provide effective ventilation when newborn is not responding to BMV before attempting intubation or initiating chest compressions.

LMA was found to offer comparable efficacy to endotracheal intubation (very low- to low-quality evidence). It therefore offers an alternate airway device when attempts at inserting endotracheal intubation are unsuccessful during resuscitation.

Most studies enrolled infants with birth weight over 1500 g or 34 or more weeks’ gestation. As such, there is lack of evidence to support LMA use in more premature infants.


(1) Orotracheal intubation in infants performed with a stylet versus without a stylet [PubMed Abstract] [HTML] [PDF].  2017 Jun 22;6:CD011791. doi: 10.1002/14651858.CD011791.pub2.

(2) Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation [PubMed Abstract] [HTML] [PDF].  2018 Mar 15;3:CD003314. doi: 10.1002/14651858.CD003314.pub3.


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