COI statement. Evolution of the LMA concept 5/24/2016. Neonatal LMA [size 1] Daniele Trevisanuto. Daniele Trevisanuto: No Conflict of Interest

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1 COI statement Advanced Ventilatory Symposium Programme Thursday 9 th June 2016 Daniele Trevisanuto: No Conflict of Interest The Use of Laryngeal Mask Airway in Neonatal Ventilation Daniele Trevisanuto Azienda Ospedaliera Padova University of Padova Only two photographs remain out of those taken to record this experiment at The London Hospital Medical Photography Department, Feb 1983 The London Hospital Ethical committee Evolution of the LMA concept Neonatal LMA [size 1] 1

2 ? VS. ADVANTAGES DISADVANTAGES - Leak pressure at cm H 2 O - Higher invasivity??? - Avoid the leak around the mask - Bypass the airway block (Berry AM, Emerg Med 1998; Tanaka, Anesthesiology 2003; Trevisanuto ADCF&N Ed) VS. VS. 2

ADVANTAGES DISADVANTAGES - Reduced invasiveness - Easier positioning - Leak pressure at 22-25 cm H 2 O - No complete seal (risk of ab ingestis) (Berry AM, Emerg Med 1998; Tanaka, Anesthesiology 2003;

3 ADVANTAGES DISADVANTAGES - Reduced invasiveness - Easier positioning - Leak pressure at cm H 2 O - No complete seal (risk of ab ingestis) (Berry AM, Emerg Med 1998; Tanaka, Anesthesiology 2003; Trevisanuto ADCF&N Ed) (Berry AM, Emerg Med 1998; Tanaka, Anesthesiology 2003; Trevisanuto ADCF&N Ed) Potential Applications of LMA in Neonates 1. Congenital airway malformations 2. Neonatal anesthesia 3. Neonatal transport 4. Neonatal resuscitation 5. Surfactant administration Potential Applications of LMA in Neonates 1. Congenital airway malformations 2. Neonatal anesthesia 3. Neonatal transport 4. Neonatal resuscitation 5. Surfactant administration Trevisanuto et al. Arch Dis Child Fetal Neonatal Ed 2004 Trevisanuto et al. Arch Dis Child Fetal Neonatal Ed 2004 Congenital Upper Airway Malformations Pierre Robin Syndrome Congenital multiple arthrogryposis Anomalies of the cervical column Cri du Chat syndrome Down syndrome Edward syndrome Freeman-Sheldon syndrome Goldenhar syndrome Hurler syndrome Neck contracture Hydrocephalus Pierre Robin syndrome Schwartz-Jampel syndrome Trachear Collins syndrome Kenny-Caffey syndrome 3

Pierre Robin Syndrome Difficult airway management in the neonate: a simple method of

intubation via the laryngeal mask: a word of caution The epiglottics may partially

Congenital airway malformations 2. Neonatal anesthesia 3. Neonatal transport 4.

Arch Dis Child Fetal Neonatal Ed 2004 Potential Applications of LMA in Neonates Laser

4 Pierre Robin Syndrome Difficult airway management in the neonate: a simple method of intubating through a laryngeal mask airway D S Ellis, Paediatric Anaesthesia, 1999 Blind intubation via the laryngeal mask: a word of caution The epiglottics may partially obstruct the distal aperture of the LMA in 25-50% of infants, but this is rarely apparent clinically. S M Auden, Pediatric Anaesthesia 2000 Potential Applications of LMA in Neonates 1. Congenital airway malformations 2. Neonatal anesthesia 3. Neonatal transport 4. Neonatal resuscitation 5. Surfactant administration Trevisanuto et al. Arch Dis Child Fetal Neonatal Ed 2004 Potential Applications of LMA in Neonates Laser therapy for ROP 1. Congenital airway malformations 2. Neonatal anesthesia 3. Neonatal transport 4. Neonatal resuscitation 5. Surfactant administration Trevisanuto et al. Arch Dis Child Fetal Neonatal Ed

Neonatal Transport case B.W. (Kg) Postnatal age at LMA insertion LMA insertion in relation to the transport time Length of LMA placement Upper airway malformations 1 3.

37* 5 min Before and during 5 h Yes Severe hypoplastic tongue * polyhydramnios Trevisanuto D et al, Pediatrics 2005 Trevisanuto D et al, Pediatrics 2005 High and profound glottis

Congenital airway malformations 2. Neonatal anesthesia 3. Neonatal transport 4. Neonatal resuscitation 5. Surfactant administration Trevisanuto et al.

5 Neonatal Transport case B.W. (Kg) Postnatal age at LMA insertion LMA insertion in relation to the transport time Length of LMA placement Upper airway malformations h During 10 min No Severe micrognathia 2 2.9* 24 h Before and during NA Yes 3 2.8* 18 h Before and during NA Yes High and profound glottis * 32 min Before 90 min Yes * 5 min Before and during 5 h Yes Severe hypoplastic tongue * polyhydramnios Trevisanuto D et al, Pediatrics 2005 Trevisanuto D et al, Pediatrics 2005 High and profound glottis High and profound glottis Trevisanuto D et al. Arch Dis Child F&N Ed 2012 Trevisanuto D et al. Arch Dis Child F&N Ed 2012 Potential Applications of LMA in Neonates 1. Congenital airway malformations 2. Neonatal anesthesia 3. Neonatal transport 4. Neonatal resuscitation 5. Surfactant administration Trevisanuto et al. Arch Dis Child Fetal Neonatal Ed 2004 Total newly born population (100) 5 to 10% requires some degree of active resuscitation at birth (for example, stimulation to breathe) 3-5% requires PPV 0.1% requires Chest Compressions, Medications 5

Positive Pressure Ventilation (interfaces) Effective positive pressure ventilation (PPV) is the most important intervention during neonatal resuscitation. Kattwinkel J (ed).

6 Positive Pressure Ventilation (interfaces) Effective positive pressure ventilation (PPV) is the most important intervention during neonatal resuscitation. Kattwinkel J (ed). Textbook of Neonatal Resuscitation. 6 th ed Face mask Laryngeal mask Tracheal tube Positive Pressure Ventilation (interfaces) Face mask Tracheal tube Laryngeal mask p<0.01 p<0.01 Van Vonderen JJ, PLOS One 2014 Van Vonderen JJ, PLOS One

Percentage Percentage Percentage 5/24/2016 Study Design Effect of a 2-minute training on the quality of face-mask ventilation in a low-resource setting FMV (Round 1) FMV (Round 2) FMV (Round 3) 1 min

trial and participant able to view data monitor) * Van Vonderen JJ, PLOS One 2014 Advanced Life Diagnostics (signed by Applied Biosignals GmbH) Effect of a 2-minute training on the quality of

7 Percentage Percentage Percentage 5/24/2016 Study Design Effect of a 2-minute training on the quality of face-mask ventilation in a low-resource setting FMV (Round 1) FMV (Round 2) FMV (Round 3) 1 min 2 min 1 min 2 min 1 min (time) Training 1* Training 2* (verbal and practical (repetition of verbal and practical demostration demostration based on 6-key points) based on 6-key points + ventilatory trial and participant able to view data monitor) * Van Vonderen JJ, PLOS One 2014 Advanced Life Diagnostics (signed by Applied Biosignals GmbH) Effect of a 2-minute training on the quality of face-mask ventilation in a low-resource setting Breaths with relevant mask leak (>25%) p< Mean: t1-89.7% (SD 21.5%) t2-45.4% (SD 27.2%) t3-18.3% (SD 20.1%) Breaths with a high PIP (>35 cm H 2 O) Breaths within recommended PIP (20-35 cm H 2 O) p< p=0.27 p=0.01 Mean: t1 19.5% (SD 32.8%) t2 39.2% (SD 37.7%) t3 6.0% (SD 15.4%) Mean: t1 7.1% (SD 12.3%) t2 41.0% (SD 33.7%) t3 61.1% (SD 29.3%) This increment was enhanced if the participant had already attended a previous neonatal course (p=0.04). 7

J Pediatr 2015) 79% PLOS One 2015 Message n.

manikin can be easy and fast Teaching effective FMV in clinical practice is

8 Trevisanuto D et al. PLOS One 2015 Effective PPV (RCT) FM (Zhu, Resuscitation 2011) 84% FM (Trevisanuto, J Pediatr 2015) 79% Trevisanuto D et al. PLOS One 2015 Message n. 1 (FMV) Positive Pressure Ventilation (interfaces) Teaching effective FMV in a manikin can be easy and fast Teaching effective FMV in clinical practice is difficult Experience of caregivers strongly influences the quality of FMV About 15-20% of late-preterm and term infants fail FMV and need Face mask Tracheal tube Laryngeal mask 8

Intubations (%) 5/24/2016 Total newly born population 5 to 10% requires some degree of active resuscitation at birth (for example,

2013 Learning curve for intubation Appropriate level of proficiency Study Acceptable failure Attempts rate at first attempt (n)

attempt 91 Author successful 2nd attempt Esophageal intubation 79 80 77 75 79 67 60 51 41 42 45 37 32 26 25 28 20 15 8 7 7 6 9 Year

9 Intubations (%) 5/24/2016 Total newly born population 5 to 10% requires some degree of active resuscitation at birth (for example, stimulation to breathe) 3-5% requires PPV 1% requires ETT Haubner LY, et al, Resuscitation 2013 Haubner LY, et al, Resuscitation 2013 Learning curve for intubation Appropriate level of proficiency Study Acceptable failure Attempts rate at first attempt (n) Mulcaster 10% 47 (Anaestesiology 2003) Konrad 10% 57 (Anesth Analg 1998) Author successful Author successful 1st attempt 91 Author successful 2nd attempt Esophageal intubation Year 1 Year 2 Year 3 Year 4 Year 5 * Total (n. 27) (n. 24) (n. 29) (n. 40) (n. 32) (n. 152) * Numbers of attempts Doglioni N et al. JMFNM

10 38 Message n. 2 (ETT) Teaching effective ETT in clinical practice is very difficult Experience of caregivers strongly influences the success of ETT Exposure to procedure is becoming rare for pediatric residents Leone TA, J Pediatr 2005 Positive Pressure Ventilation (interfaces) International Liaison Committee on Resuscitation (ILCOR) Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Part VII. Neonatal resuscitation. (JAMA, Oct 1992) Face mask Tracheal tube Laryngeal mask Bloom RS, Cropley C, editors. Textbook of neonatal resuscitation AHA committee on cardiopulmonary resuscitation (adults) Empirical observations [1987] [1966] [<1960] [1992] [2000] [2005] [2010] Guidelines for Neonatal Resuscitation (history) [2015] Laryngeal Mask Airway: when? International Guidelines for Neonatal Resuscitation, 2000 Laryngeal Mask may be an effective alternative for establishing an airway during resuscitation of the newly born infant, in case of failure of facial mask ventilation and/or tracheal intubation (Class Indeterminate). AHA, AAP, Pediatrics

Laryngeal Mask Airway: when? 2000 International Guidelines for Neonatal Resuscitation Neonatal resuscitation 1. SJ Paterson, Anesthesiology 1994;80:1248-1253 2.

11 Laryngeal Mask Airway: when? 2000 International Guidelines for Neonatal Resuscitation Neonatal resuscitation 1. SJ Paterson, Anesthesiology 1994;80: D Gandini, JR Brimacombe, Anesth Analg 1999;79: enrolled neonates 3. D Trevisanuto, Resuscitation 2004;62: D Trevisanuto, Arch Dis Child Fetal Neonatal Ed 2004 Neonatal resuscitation 2005 International Guidelines for Neonatal Resuscitation Effectiveness (%) AHA, AAP, Pediatrics 2006 D Trevisanuto, Arch Dis Child Fetal Neonatal Ed 2004 Laryngeal Mask Airway: when? 2005, 2010 International Guidelines for Neonatal Resuscitation Perlman JM et al. Pediatrics,

REVERSE LMA INSERTION IN A NEONATE WITH KLIPPEL-FEIL SYNDROME

REVERSE LMA INSERTION IN A NEONATE WITH KLIPPEL-FEIL SYNDROME - Case report - TARIQ AL ZAHRANI * Klippel-Feil syndrome (KFS) was first described by Maurice Klippel and Andre Feil in 1912 in a patient with