Laryngeal mask airway for surfactant administration in neonates: a practical guide
Non-invasive respiratory support has become a focus of clinical application for early management of preterm infants with respiratory distress syndrome (RDS)1-6. While non-invasive respiratory (NIV) support avoids the negative effects of intubation and ventilator-induced lung injury, failure of this mode of support is relatively frequent and primarily caused by surfactant deficiency7. Fortunately, surfactant can still be administered in a minimally invasive manner through a laryngeal mask airway (LMA), thereby gaining the benefits of surfactant while maintaining non-invasive respiratory support.
The aim of this practical guide and video is to provide instruction for medical personnel on the indications, contraindications, necessary equipment, and LMA placement and surfactant administration technique.
Indications and contraindications
Thresholds for treatment will vary and need to be customized to individual institutional practices. General guidelines include:
- Requiring non-invasive respiratory support (i.e. continuous positive airway pressure, high flow nasal cannula or non-invasive ventilation)
- Weight ≥ 1250 grams (limited by size of currently available LMAs)
- Clinical diagnosis of RDS (grunting, retracting, nasal flaring)
- Requiring FiO2 ≥ 22%
Thresholds for treatment must take into account multiple factors, including exposure to prenatal steroids, gestational age, time since birth, FiO2 requirement, PaCO2, clinical symptoms and chest radiographic findings.
The goal of LMA surfactant administration is to intervene early enough in the course of RDS to avoid need for intubation and mechanical ventilation while avoiding unnecessary procedures in infants who would be successful on NIV alone.
Intervening early in the course of disease is important. Sub- analysis of the Roberts trial found that infants enrolled at a lower FiO2 and an earlier age were more likely to avoid intubation8. These findings were likely due to timing of the intervention in relation to progression of atelectasis. When considering FiO2 requirement, is it the trend, as opposed to the absolute value, that is most important, as this is an indirect marker for degree of atelectasis. Decreasing FiO2 indicates improvement and further time on NIV alone is prudent. Increasing FiO2 or worsening clinical symptoms indicate worsening atelectasis and LMA surfactant should be given to interrupt the progression. General guidelines include:
|Relatively high FiO2 (50-60%), infant newly born and transitioning||If FiO2 is decreasing, hold on surfactant administration and follow trend.
Decision to administer surfactant based on FiO2 plateau and degree of symptoms.
|FiO2 25-40%||If FiO2 is stable or increasing, administer surfactant|
|FiO2 22-25%||Decision based on degree of symptoms and trend|
|FiO2 21%||Surfactant not indicated|
Contraindications include an etiology for respiratory distress other than RDS (such as congenital diaphragmatic hernia, pulmonary hypoplasia, hypoxic-ischemic encephalopathy, meconium aspiration syndrome, pneumonia), severe apnea despite caffeine administration, major congenital anomaly and/or abnormality of the airway or lungs. Presence of a pneumothorax is a relative contraindication.
In the case of high oxygen requirement, severe respiratory acidosis and/or significant atelectasis on chest radiograph, LMA surfactant is unlikely to be sufficient and would result in an unnecessary procedure and delay implementing appropriate treatment. In these cases, it is recommended to proceed directly to intubation and treatment with surfactant through an endotracheal tube.
The necessary equipment is discussed below. Products listed serve as examples of what is available and not intended to be an all-inclusive list or to promote a specific product. Providers should adapt the equipment to what is available or obtainable at their institution.
Necessary equipment includes:
Laryngeal Mask Airway (LMA)
LMAs fall under the category of supraglottic airway devices (SAD). Several companies manufacture SADs, with the LMA brand being the oldest and most widely recognized. In this practical guide, LMA will be used in the generic sense, referring to the category of SADs, rather than to a specific manufacture or device.
LMAs available for use in neonates differ in size, shape, re-use designation (single- use versus reusable), and cuff characteristics (inflatable versus non-inflatable). Examples of LMAs available and their characteristics are shown in Figure 1.
A study comparing LMA devices tested in a manikin model found the iGel® (Intersurgical®) to be superior9.
Use of a CO2 detector during placement of the LMA allows for instantaneous feedback regarding proper positioning of the LMA over the trachea. CO2 detection methods are shown in Figure 2 and include:
- Capnography: CO2 detection displayed as a waveform and digital value
- Colorimetric: CO2 detection indicated by color change
The mask of the LMA rests in the posterior pharynx at the bifurcation of the tracheal and esophagus. Therefore, proper placement is crucial to ensure surfactant is directed into the trachea. If the mask is not fully over the tracheal opening, CO2 will still be detected, but surfactant will leak into the esophagus. Use of capnography dramatically improves “fine-tuning” of device placement. Compared to a colorimetric CO2 detector, which has subtle color change variance with the amount of CO2 detected, capnography allows the provider to subtly advance and retract the LMA to optimize mask placement over the tracheal opening.
Use of an adapter allows for continuous positive end-expiratory pressure (CPAP) to be delivered without interruption throughout the entire procedure.
Note: The procedure can be performed without an adapter, but CPAP will be disconnected during administration of surfactant resulting in possible loss of functional residual capacity (FRC). Adapter options are shown in Figure 3 and include:
- “T” adapter: Surfactant syringe attaches to side port, CO2 detector attaches to anterior hub
- “Y” adapter: Surfactant administration occurs through one limb, CO2 detector attaches to second limb of the “Y” piece
If using a “Y” adapter, additional equipment is need and includes:
- 8F Feeding tubeAllows for instillation of surfactant to the distal end of the LMA, thereby reducing the potential for air bubbles to develop in the body of the LMA during surfactant administration
- ScissorsNecessary to cut the feeding tube to the proper length to administer surfactant to the distal end of the body of the LMA
- Tape measureNecessary to measure the proper length to cut the feeding tube
- Catheter adapter (aka Christmas tree adapter)Necessary to attach the syringe containing the surfactant to the feeding tube
Use of a “T” adapter is preferable as it allows for the syringe containing surfactant to be directly connected to the adapter and eliminates the need for the 4 additional items needed when using a “Y” adapter.
Use of a ventilation device allows for PEEP to be given during the procedure, which is crucial for avoiding loss of FRC and potential de-recruitment of the lungs. A ventilation device also allows for PPV to be used to distribute the surfactant and to provide rescue breaths if desaturation or bradycardia were to occur.
- T-piece resuscitator
- Ambu bag (self-inflating, anesthesia bag)
Use of a T-piece resuscitator or anesthesia bag is preferable as PEEP is continuously maintained, even if PPV is not being administered. In contrast, when using a self-inflating ambu bag, PEEP is only administered when a positive pressure breath is delivered, therefore PPV breaths must be given throughout the procedure to maintain PEEP.
Appropriately sized equipment should be readily available to convert to bag-mask ventilation or intubation if significant desaturation or bradycardia were to occur.
- Intubation supplies
It is recommended to create an “LMA Surfactant Supply Kit” containing the supplies and procedure guidelines (Figure 4).
Prior to the procedure, confirm that necessary equipment is present at the bedside.
Confirm the infant has an oro-gastric (OG) or naso-gastric (NG) tube and a functioning intravenous catheter in place. If the surfactant syringe will be attached to a feeding tube, pre-cut an 8 French feeding tube to a length where the distal end of the feeding tube is in the lower half of the body of the LMA (if using a “Y” adapter with an iGel or LMA Unique, the appropriate length would be 14 cm). It is also recommended to calculate the appropriate dose of a rapid-onset paralytic in the unlikely event that laryngospasm were to occur.
A flowchart of the procedure is shown in Figure 5.
Premedication with a 24% sucrose solution and atropine (0.02 mg/kg IV over 1 minute) is recommended, but not required. Late preterm and term infants often benefit from a dose of lorazepam (0.05- 0.1 mg/kg IV).
Position the infant in the bed similar to positioning for intubation. Swaddle, while maintaining visualization of the chest, and have a provider dedicated to holding and observing the infant during the procedure. Maintain appropriate body temperature.
Position the infant supine, with the body straight, a shoulder roll in place, and head midline in the “sniffing” position. Proper positioning is essential for proper placement of the LMA. Aspirate stomach contents (NG/OG can remain in place). The NIV interface is left in place but can be removed if it interferes with placement of the LMA. Of note, the infant will not be receiving PEEP through the nasal device as the LMA will occlude the trachea, rather, PEEP will be delivered through the LMA. Attach the adapter to the proximal end of the LMA. Attach the CO2 detector to the adapter. If the LMA has a cuff, slightly inflate the cuff (just enough so the cuff is not completely collapsed, as this will help ensure the tip does not curl with placement).
Standing behind the infant’s head, open the mouth and grasp the tongue with the left hand. Insert the LMA with the right hand, using the index finger to guide the LMA along the curvature of the hard palate. Gentle pressure may be required initially as the cuff tends to grasp the tongue, but will insert easily once past the tongue. Advance the LMA until CO2 is detected and resistance to further advancement is felt. On larger infants, the index finger may not be long enough to fully advance the LMA. Further advancement can occur by holding the body of the LMA between the thumb and index finger. Once resistance is felt and CO2 detected, the mask is in the pharyngeal “pocket”. Once in the pocket, slightly advance and then slowly retract the LMA. This maneuver places the tip of the mask in the esophagus and upon retraction, captures the epiglottis and holds it against anterior wall, maintaining the epiglottis in the open position. Optimize placement over the tracheal opening by optimizing CO2 detection and while subtle adjustments (advancement and retraction) are made with the LMA. Once optimized, hold the LMA in place and attach the ventilation device to the CO2 detector.
Initiate ventilation and confirm proper positioning indicated by the CO2 detector and listening for bilateral breath sounds. If breath sounds and CO2 detection are not optimized, subtly readjust the LMA. If subtle re-adjustments do not result in proper positioning, remove the LMA (deflate cuff prior to removal if using an LMA with an inflatable cuff), stabilized the infant and repeat LMA placement. Placement attempts should be limited to 30 seconds.
Once proper placement of the LMA is achieved, administer surfactant in 2 ml aliquots. Administer the next aliquot once surfactant had cleared from the LMA, as determined subjectively by feel if using bag ventilation, SaO2 ≥ 94% and heart rate ≥100 beats per minute (bpm). If using PPV, surfactant has usually clears within 3-4 breaths. After administration of the last aliquot, continue PEEP and/or PPV until SaO2 ≥ 94% and heart rate ≥100 bmp. Remove the LMA (if using an LMA with an inflatable cuff, deflate cuff prior to removal).
Place infant back on NIV and adjust as needed. Verify proper OG/NG placement and readjust or replace if needed. Aspirate stomach contents, noting amount aspirated relative to amount administered (gastric aspirate is an imprecise indicator, as all of the surfactant may not have been aspirated and/or the gastric aspirate may represent gastric secretions or other medications in addition to surfactant, but relative amount does provide an estimate of potential leakage around the cuff). Return the infant to their normal position in the bed.
During the procedure, if SpO2 < 75% or heart rate <100 bpm, the procedure should be interrupted and PPV administered via the LMA or a mask until Sp02 > 94% and heart rate > 100 bpm. If the infant does not respond satisfactorily, appropriate therapy, which may include intubation and mechanical ventilation, should be instituted to achieve stable cardiopulmonary function.
If the LMA is positioned too high or too deep in the pharynx, the cuff will not form a seal and surfactant will leak into the esophagus. After the procedure, if there is a large percentage of the dose aspirated from the stomach and a lack of clinical response (i.e. lack of decrease in FiO2/ respiratory support requirement within the first minutes after instillation), the procedure may be repeated immediately through the LMA.
After the initial procedure, if additional doses of surfactant are deemed necessary by the clinical provider, additional doses may be given through the LMA at the appropriate time.
While placement and surfactant administration through an LMA generally results in minimal fluctuation in physiologic parameters, bradycardia, hypoxia, hypotension and/or hypertension may occur and should be anticipated. The infant should be continuously monitored and personnel skilled in bag- mask ventilation and intubation should be present at the bedside.
Since the LMA rests in the posterior pharynx and surfactant is administered above the glottis (as compared to administration via an endotracheal tube which is delivered below the vocal cords), laryngospasm is a potential complication. In animal and human trials8,10-14 and in clinical experience, laryngospasm has not be reported. However, because it is a theoretic risk, a muscle relaxant and personnel skilled in intubation should be readily available.
In the Roberts trial8, providers had minimal or no prior experience placing an LMA. Training occurred by reviewing the procedure on a manikin. Successful placement of the LMA was achieved in < 35 seconds and on the first attempt in the majority of patients15. Providers stated they felt comfortable with the procedure after 2 experiences.
Administering surfactant through an LMA allows the infant to obtain surfactant in a minimally invasive manner and maximize potential for success on NIV. Incorporating this procedure into clinical practice is feasible and relatively easy to learn.
- Finer NN, Carlo WA, Walsh MC, Rich W, Gantz MG, Laptook AR, et al; SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network. Early CPAP versus surfactant in extremely preterm infants. N Engl J Med 2010; 362:1970–1979.
- Dunn MS, Kaempf J, de Klerk A, de Klerk R, Reilly M, Howard D, et al; Vermont Oxford Network DRM Study Group. Randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates. Pediatrics 2011; 128:e1069-76.
- Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB; COIN Trial Investigators. Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med 2008; 358:700–708.
- Schmolzer GM, Kumar M, Pichler G, Aziz K, O’Reilly M, Cheung PY. Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis. BMJ 2013; 347:f5980.
- Committee on Fetus and Newborn; American Academy of Pediatrics. Respiratory support in preterm infants at birth. Pediatrics 2014; 133:171–174.
- Fischer HS, Bührer C. Avoiding endotracheal ventilation to prevent bronchopulmonary dysplasia: a meta-analysis. Pediatrics 2013; 132:e1351-60.
- Dargaville PA, Gerber A, Johansson S, De Paoli AG, Kamlin OF, Orsini F, et al. Incidence and Outcome of CPAP Failure in Preterm Infants. Pediatrics 2016; 138: e20153985.
- Roberts KD, Brown R, Lampland AL, Leone TA, et al. Laryngeal mask airway for surfactant administration in neonates: A randomized, controlled trial. J Pediatr 2018; 193: 40-46.
- Tracy MB, Priyadarshi A, Goel D, et al. How do different brands of size 1 laryngeal mask airway compare with face mask ventilation in a dedicated laryngeal mask airway teaching manikin? Arch Dis Child Fetal Ed 2018; F271-276.
- Roberts KD, Lampland AL, Meyers PA, Worwa CT, Plumm BJ, Mammel MC. Laryngeal mask airway for surfactant administration in a newborn animal model. Pediatr Res 2010; 68:414-418.
- Attridge JT, Stewart C, Stukenborg GJ, Kattwinkel J. Administration of rescue surfactant by laryngeal mask airway: lessons from a pilot trial. Am J Perinatol 2013; 30:201-206.
- Sadeghnia A, Tanhaei M, Mohammadizadeh M, Nemati M. A comparison of surfactant administration through i-gel and ET-tube in the treatment of respiratory distress syndrome in newborns weighing more than 2000 grams. Adv Biomed Res 2014; 3: 160.
- Pinheiro JMB, Santana- Rivas Q, Pezzano C. Randomized trial of laryngeal mask airway versus endotracheal intubation for surfactant delivery. J Perinatol 2016; 36: 196-201.
- Barbosa RF, Simoes e Silva AC, Silva YP. A randomized controlled trial of the laryngeal mask airway for surfactant administration in neonates. J Pediatr 2017; 93:343-350.
- Wanous AA, Wey A, Rudser KD, Roberts KD. Feasibility of Laryngeal Mask Airway Device Placement in Neonates. Neonatology 2016; 111:222-227.
Figure 1. Layngeal Mask Airways
Size 1 LMAs. (1) Ultimate (Ultimate Medical, Tianjin Medis, China), (2) PRO-Breathe (Well Lead Medical, China), (3) LMA Supreme (The Laryngeal Mask, Seychelles), (4) Unique LMA (The Laryngeal Mask), (5) air-Qsp (Cookgas, Malaysia), (6) AuroOnce (Ambu A/S, Ballerup, Denmark) and (7) i-gel (Intersurgical, Wokingham, Berkshire, UK). Used with permission from Tracy MB. Arch Dis Child Fetal Neonatal Ed 2018;103:F271–F276.
Figure 2. Carbon Dioxide Detectors
A. Capnography: EMMA™ Capnography, Massimo, Irvine, CA (portable); CO2 detector pod added to a bedside monitor
B. Colorimetric detectors: PediCap®, Nellcor, Boulder, CO; NeoStat®,Mercury Medical, Auckland, New Zealand
Figure 3. Adapters
“T” piece: MC-1515, Medicomp, Princeton, MN; “Y-piece”: Neo-Verso Airway Access Adapter CSC200, CareFusion, Yorba Linda, California.
Figure 4. LMA Surfactant Supply Kit
The LMA Surfactant Supply Kit contains supplies and procedure guidelines. A label, supply list and designation of personnel responsible for restocking the supplies should be clearly defined on the container.
Figure 5. Flowchart of the LMA Surfactant Procedure
LMA for surfactant administration procedure guidelines.