Use of Supraglottic Airways during Neonatal Chest Compressions: NLS 5342 TF ScR

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. None of the authors have any conflicts of interest to declare.

Task Force Scoping Review Citation

Ramachandran S, Soh QH, and Wyckoff MH on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Use of Supraglottic Airways During Neonatal Chest Compressions Scoping Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force, 2024, Oct 31. Available from: http://ilcor.org

Methodological Preamble

The continuous evidence evaluation process started with a scoping review of the literature examining the use of the supraglottic airway devices (SGAD) during chest compressions in neonatal resuscitation. This search was conducted by the ILCOR NLS Task Force and Content Expert Scoping Review Team comprised of Shalini Ramachandran, MD, Qian Hui Soh, MBBS and Myra Wyckoff MD. Relevant studies were sought using a structured search strategy with the help of two information specialists - David Honeyman (GradDipAppSci) from the University of Queensland and Stan Earnshaw (BSc, GradDipInfoStud) from Gold Coast University Hospital, QLD Australia. Studies identified were evaluated using Covidence systematic review software (Melbourne, Australia). Articles selected by independent title and abstract review by two authors (SR and QHS) were included for full text review. Conflicts were resolved by consensus or adjudication of a third reviewer (MW).. The Neonatal Life Support Task Force considered the findings for the PICOST and developed Task Force insights..

Link to Published Scoping Review-not yet available

PICOST ( Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: In newborn infants of 34 or more weeks’ gestation receiving chest compressions despite optimized positive pressure ventilation

Intervention: does administering positive pressure ventilation with a supraglottic airway device (SGAD)

Comparators: versus administering positive pressure ventilation with a face mask or endotracheal tube (ET)

Outcomes: impact on short and long term outcomes such as:

DELIVERY ROOM OUTCOMES

• Death in delivery room (Critical)

• Time to heart rate (HR) > 60 beats per minute (bpm) (Important)

• Time to HR > 100 bpm (Important)

• Duration of advanced airway placement attempt / Duration of interruption of cardiopulmonary resuscitation (CPR) (Important)

• Number of attempts to insert advanced airway (Important)

• Epinephrine (adrenaline) administration (Important)

• Team preference (Important)

• Failure of primary device (Important)

• Physiologic pulmonary outcomes (e.g., tidal volume, peak inspiratory pressure) (Important)

NICU OUTCOMES

• Air leak (e.g. pneumothorax, pneumomediastinum) during first 48 hours of life (Important)

• Airway injury (Important)

• Length of hospital stay (Important)

• Survival to hospital discharge (Important)

• Incidence of hypoxic ischemic encephalopathy (Critical)

LONG TERM OUTCOMES

• Neurodevelopmental impairment at >18 months (Critical)

Importance was assigned to outcomes in accord with consensus of the NLS Task Force and other experts. {Strand 2020 F328, Webbe 2020 425}

Study Design: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) and animal studies were eligible for inclusion. Non-peer reviewed studies, unpublished studies, conference abstracts and trial protocols were also eligible for inclusion.

Timeframe: All years and all languages were included as long as there was an English abstract

Search Strategies

Pubmed July 15, 2024

("Respiratory Distress Syndrome, Newborn"[Mesh] OR "Bronchopulmonary Dysplasia"[Mesh] OR "Infant, Newborn"[Mesh] OR "Delivery Rooms"[Mesh] OR "Gestational Age"[Mesh] OR "Premature Birth"[Mesh] OR "Infant, Premature, Diseases"[Mesh:NoExp] OR "Term Birth"[Mesh] OR "Live Birth"[Mesh] OR "Neonatal Nursing"[Mesh] OR "Neonatal Screening"[Mesh] OR "Intensive Care, Neonatal"[Mesh] OR "Intensive Care Units, Neonatal"[Mesh] OR "Transient Tachypnea of the Newborn"[Mesh] OR "Persistent Fetal Circulation Syndrome"[Mesh] OR "Low Birth Weight "[tiab] or "Small for Gestational Age"[tiab] or prematur*[tiab] or preterm[tiab] OR pre-term[tiab] OR "Birth Injuries"[Mesh] OR "Birthing Centers"[Mesh] OR Postmature[tiab] OR birth[tiab] OR newborn*[tiab] OR new-born*[tiab] OR "newly born" OR neonat*[tiab] OR neo-nat*[tiab] OR infant*[tiab] OR "low birth weight" OR "low birthweight" OR VLBW OR LBW OR postnatal OR post-natal OR "Infant, Newborn"[Mesh] OR "Perinatal Care"[Mesh] OR "Animals, Newborn"[Mesh])
AND
(resuscitat*[tiab] OR compression*[tiab] OR Heart Massage[MeSH Terms] OR "heart massage*"[Title/Abstract] OR "cardiac massage*"[Title/Abstract] OR "Cardiopulmonary Resuscitation"[Mesh] OR "positive pressure"[TW] OR "Positive-Pressure Respiration"[Mesh] OR "Resuscitation"[Mesh] OR "Asphyxia Neonatorum"[Mesh])
AND
("supraglottic*"[tiab] OR "supra-glottic*"[tiab] OR SGA[tiab] OR "laryngeal airway*"[tiab] OR "laryngeal tube*"[tiab] OR i-gel[tiab] OR "supralaryngeal airway*"[tiab] OR "laryngeal mask*"[tiab] OR LMA[tiab] OR "Laryngeal Masks"[Mesh])

Embase July 15, 2024

Cochrane Library July 15, 2024

Inclusion and Exclusion criteria

RCTs and non-randomized studies (Non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) and animal studies were eligible for inclusion. Non-peer reviewed studies, unpublished studies, conference abstracts and trial protocols were also eligible for inclusion. All years and all languages were included if there was an English abstract.

• Imported for screening; 810 records, of which 53 duplicates were identified and removed by Covidence
• Screened: 757, of which 725 were deemed irrelevant
• Full text articles considered: 32 (reasons for exclusion were; wrong patient population (13), wrong study design (6), full text article not available (1), correction to published article (1), letter to editor (1), wrong comparator (4), wrong intervention (1).
• Included: 5 studies

Data Tables

Table 1: Studies in neonatal animal models or manikins of SGAD vs ET.

Table 2: Studies in other (non-neonatal) animal models of SGAD vs ET use for epinephrine administration.

Task Force Insights

1. Why this topic was reviewed

Transition from intrauterine to extrauterine life involves major physiological changes, including aeration of lungs and airway liquid clearance, establishment of pulmonary gas exchange and cardiovascular transition. {Hooper 2015 147} It is estimated that 5-10% newborns require some intervention to initiate breathing at birth. {Wyckoff 2020 S185, Wyckoff 2020 A156} Therefore, establishment of effective ventilation to provide lung aeration and subsequent increase in pulmonary blood flow is prioritized. {Sankaran 2022 151620} However, some newborns require more assistance and a small proportion about 0.1% newborns receive chest compression in the delivery room. {Perlman 1995 20, Ramachandran 2023 442} Since it is strongly recommended to have an advanced airway placed when chest compressions are required, ventilation is frequently initiated with bag mask ventilation followed by placement of an advanced airway such as endotracheal tube (ET). {Qureshi 2018 CD003314, Yamada 2022 e2022056568}

Despite being one of the most frequently used interfaces for ventilation, the efficacy of bag mask ventilation can be compromised by leaks around the mask or upper airway obstruction leading to inadequate tidal volume. {Yamada 2022 e2022056568} Reduced tidal volume and minute volume with bag mask use during chest compressions has been reported. {Song 2024 240} Some regional neonatal resuscitation guidelines encourage placement of an advanced airway when chest compressions are needed. {Aziz 2021 Suppl 1, Aziz 2020 S524} Although considered the gold standard for advanced airways, placement of an endotracheal tube is a specialized skill which requires training and experience that is increasingly difficult to obtain. {Pinheiro 2023 361} Hence a supraglottic airway (SGAD) may be a plausible alternative for providing effective positive pressure ventilation during chest compressions in settings where providers trained in neonatal intubation are not readily available or intubation attempts have been unsuccessful.

An ILCOR systematic review comparing SGADs with facemasks for neonatal resuscitation suggests that ventilation may be more effective if delivered by a SGAD rather than facemask and may reduce the need for endotracheal intubation. {Yamada 2022 e2022056568} A Cochrane review comparing SGADs to bag mask ventilation and endotracheal intubation suggested that ventilation via a supraglottic airway was superior to bag mask ventilation in terms of shorter resuscitation and ventilation times. In cases where SGADs were used as rescue when bag mask ventilation had failed, intubation was avoided in many instances. {Qureshi 2018 CD003314} In addition, SGADs are less invasive and relatively easy to insert without laryngoscopy. Supraglottic airways have been widely used in adult and paediatric patients, albeit not so commonly in the neonatal population. {Benger 2018 779, Forestell 2024 e89, Le Bastard 2021 191, Lee 2022 e2148871, Mulder 2013 S17, Song 2024 240, Trevisanuto 2015 286, Wang 2020 627, Wang 2018 769, Yamada 2022 e2022056568} Nevertheless, the feasibility of supraglottic airway as the interface for positive pressure ventilation during neonatal resuscitation has been reported for over 20 years. {Yamada 2022 e2022056568} However, it remains an important question if SGAD is an effective alternative to endotracheal intubation during chest compressions. Thus, the International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support (NLS) Task Force prioritized the current scoping review to review the evidence on use of supraglottic airway during neonatal chest compressions.

2. Narrative summary of evidence identified

Three studies were identified that addressed the use of supraglottic airways during chest compressions in newborn models. {Isobe 2022 100276, Mani 2022 671, Mehrem 2014 e57} Two were animal studies, {Mani 2022 671, Mehrem 2014 e57} and one was a manikin crossover study. {Isobe 2022 100276} No studies in human newborn infants were found.

Impact of SGAD use during chest compressions on respiratory parameters and return of spontaneous circulation (ROSC) in newborn models.

Three studies compared ventilatory parameters when SGADs were used as the airway interface during chest compressions as compared to facemask or endotracheal tube (ET) {Isobe 2022 100276, Mani 2022 671, Mehrem 2014 e57} Mani et al used a newborn transitional lamb model of asphyxia to compare time to ROSC when SGADs vs ETs were used as the respiratory interface during chest compressions. {Mani 2022 671} Similar rates of ROSC were achieved (SGAD 75% vs ET 56%; p=0.74) and ROSC was achieved within a similar time (SGAD; 6 min 51 sec vs ET; 7 min 30 sec p=0.65). No differences in peak inspiratory pressure (PIP), positive end inspiratory pressures (PEEP), tidal volume (TV) or mean airway pressure (MAP) were found, leading the authors to conclude that use of the SGAD is non-inferior to use of an ET during chest compressions. Similarly, Mehrem et al reported comparable tidal volumes and PIPs between SGAD and ET ventilation during neonatal chest compressions (mean difference 1.6 cm H₂O; 95% confidence interval (CI) 0.12-3.1 cm H₂O) using a neonatal piglet model of asphyxia induced arrest. {Mehrem 2014 e57} A crossover manikin study evaluating single rescuer CPR with either an SGAD or facemask as the respiratory interface demonstrated higher PIPs achieved with the SGAD compared to the facemask (28.2±2.0 vs 17.3±4.4 cm H₂0, p < 0.00001). {Isobe 2022 100276} The time taken to complete 30 compression:ventilation cycles was shorter with the SGAD vs facemask (60.6±3.4 sec vs 66.2±6.1 sec; p<0.0001) which allowed for better adherence to the Neonatal Resuscitation Program recommendations of completing 120 events in 60 sec. {Weiner 2021 }

Impact of SGAD use during chest compressions in older populations

Substantial clinical data regarding use of SGAD during chest compressions is available in older populations . A large French retrospective registry study in the pediatric age group (<18 years) assessed the impact of respiratory support via ET vs SGAD during cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest on 30 day survival. {Le Bastard 2021 191} ET use during CPR was associated with lower rates of survival compared to SGAD. These findings should be interpreted with the understanding that this was not a randomized controlled trial and it is possible that sicker children were intubated. However, this is in keeping with other pediatric studies which found worse outcomes with endotracheal intubation during CPR. {Andersen 2016 1786, Hansen 2017 51}

Adult clinical data supports use of SGAD during CPR. A 2020 systematic review and network meta-analysis by Wang et al (11 studies including 8 RCTs) compared effectiveness of different airway interventions for out-of-hospital cardiac arrest. {Wang 2020 627} There was increased ROSC with use of SGAD compared to ET (odds ratio 1.11; 95% CI 1.03 to 1.20) or compared to bag mask ventilation (odds ratio 1.35; 95% CI 1.11 to 1.63). No differences in survival or long term neurological outcomes amongst the different airway interventions were found. A later systematic review and meta-analysis which examined use of SGAD vs ET in adults with out-of-hospital cardiac arrest concluded that it took less time to place an SGAD (mean difference 2.5 min less; 95% CI, 1.6-3.4 min less; high certainty) and use of an SGAD likely led to more ROSC (relative risk 1.09; 95% CI, 1.02-1.15; moderate certainty). {Forestell 2024 e89}

Epinephrine administration during cardiopulmonary resuscitation

No studies investigating efficacy of epinephrine via supraglottic airway administration in newborn infants or newborn animal models were identified. Two studies investigated the efficacy of epinephrine administered via SGAD in an adult non-cardiac arrest porcine model. Chen et al divided twenty four adult pigs into four groups and administered 20 mg/kg of IV epinephrine (group 1), 50mg/kg of endotracheal epinephrine (group 2), 50 mg/kg of epinephrine via top of the SGAD (group 3) and 50 mg/kg of epinephrine via a catheter inserted through the SGAD into the trachea (group 4). {Chen 2006 503} The plasma levels of epinephrine were measured at regular intervals as were vital signs such as heart rate and mean blood pressure. A difference in peak plasma epinephrine levels (p=0.002) was found with the highest levels achieved in group 1 (IV) and lowest in group 3 (top of the SGAD). There was no difference in epinephrine levels between groups 2 (ET) and 4 (SGAD with catheter inserted to trachea). While there was an elevation in heart rates in all four groups after epinephrine administration, peak heart rate was achieved faster in group 1 (IV) compared to the other groups which had peak heart rate elevation around 4 minutes after administration (p=0.036). The highest heart rates were noted in group 1, the lowest in group 3 and similar peak heart rates were observed in groups 2 and 3. A similar trend was noted in mean blood pressure with only group 1 achieving significant elevation after administration of epinephrine (p=0.036). Given these data, the authors concluded that epinephrine administration via catheter passed through the SGAD had similar effects as administering it via an endotracheal tube but that if administering epinephrine from the top of the SGAD, that higher doses would be needed.

Liao et al examined optimal epinephrine dosing when administered via a SGAD. {Liao 2010 25} Using the same adult non-arrest porcine model, five different routes and doses of epinephrine were compared. Epinephrine administered at the top of the SGAD was given in higher doses than the ET route due to the results of the previous study. {Chen 2006 503} Control animals received 10 ml of distilled water via ET; a second group received 50mg/kg of epinephrine via the ET; Additional groups received epinephrine via the SGAD route at 100 µg/kg, 200 mg/kg, and 300 mg/kg. Both the ET group and the SGAD-300 µg/kg group had significant increases in systolic blood pressure (p=0.028; both groups), with the peak SBP noted to be earlier and higher in the ET group at 2 mins but the effect lasting longer in the SGAD-300 µg/kg group. They also demonstrated a similar rise in diastolic blood pressures and mean arterial pressures in both those groups. Notably, while the heart rates increased in both these groups, the peak heart rate was significantly higher in the ET group compared to the SGAD-300 µg/kg group (p=0.01). The control, SGAD-100 µg/kg, and SGAD-200 mg/kg groups failed to demonstrate significant changes in the hemodynamic parameters that were measured. The authors concluded that higher doses of epinephrine may be required if administering the epinephrine at the top of the SGAD in order to produce an equivalent effect to epinephrine administered via ET.

3. Narrative Reporting of the NLS Task Force discussions

• The Task Force notes the lack of any neonatal clinical data.
• Limited animal data suggests that ventilation via SGAD during chest compressions provides similar rates of ROSC when compared to ET.
• Limited animal data suggestions that time to ROSC is similar when SGAD vs ET is used to provide ventilation during chest compressions.
• Animal and manikin data suggest that SGAD can deliver comparable ventilation to that provided through an endotracheal tube during chest compressions.
• Clinical data from pediatric and adult populations in chest arrest suggest that SGAD has advantages in decreased time to airway placement and increased percent of patients who achieve return of spontaneous circulation when compared to bag mask ventilation or endotracheal intubation during cardiac compressions.
• Neither the neonatal animal studies nor the older pediatric and adult clinical studies demonstrated any significant complications from use of SGAD.
• Regarding epinephrine delivery via SGAD, the adult non-arrest model data suggests that to do this a catheter would have to be inserted to the level of the trachea or much higher doses of epinephrine would be needed. Given the lack of data in cardiac arrest models or human data, the task force felt more studies would be needed before any judgement could be made on the utility of epinephrine via SGAD.
• The Task Force recognized that caution should be exercised when assuming external validity of pediatric and adult studies to the newborn infant given the unique transitional cardiopulmonary physiology that occurs at the time of birth. In older age groups, cardiac causes are more common, as opposed to neonates in whom arrest is usually due to lack of gas exchange. This underscores the critical role of an effective respiratory interface to provide ventilation during cardiac compressions in neonates.
• However, endotracheal tube placement is a specialized skill that is increasingly difficult to acquire. In instances where personnel skilled in endotracheal intubation are not immediately available, or intubation has been unsuccessful, SGAD placement would offer an alternative to continued attempts at intubation. Hence, an argument can be made to use an SGAD on a case by case basis depending on the size of the team and the skills of the people immediately available.
• Given the lack of clinical data, the task force felt there was no basis for escalation to a systematic review.
• However, the Task Force felt it was reasonable to suggest the following good practice statement:

In newborn infants of of 34 or more weeks’ gestation, receiving chest compressions despite optimized positive pressure ventilation, if placement of an endotracheal tube is not possible or is unsuccessful, ventilation during compressions with a supraglottic airway device is reasonable. (Good Practice Statement)

Knowledge Gaps

• Human neonatal clinical data are needed
• More studies targeting hemodynamic data would be helpful to better understand the impact of use of different respiratory interfaces in cardiopulmonary resuscitation.
• Pharmacodynamics of drug delivery via supraglottic airways in newborn cardiac arrest models and humans is needed.

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