| [Background]Recently, an expert group from the China newborn resuscitation project published the6th edition of its neonatal resuscitation guide. Technical training teams for Neonatal resuscitation have been established throughout the country. However neonatal asphyxia is still, at present a major cause of neonatal death and impaired intelligence. According to the national maternal and child health monitoring, in2005, the main reasons for neonatal death were:premature birth, low birth weight, asphyxia and pneumonia (Nearly a quarter of premature infants suffer from asphyxia). The proportion dying of asphyxia among children under the age of five was20.5%, and stands as the second leading cause.Additionally, according to two authoritative neonatal epidemiological investigations, the incidence of neonatal asphyxia in62hospitals throughout our country (including42provincial capital hospitals) was4.8%, and even in the developed district of zhongnan,23hospitals (including11provincial capital hospitals), was as high as3.78%, as compared to between5%and11%in the developing districts. In developed countries, neonatal mortality due to asphyxia has been reduced to less than1‰～2‰, distinctly contrasting with the much higher mortality rates in China. The survey found the main reason for this was that the resuscitation workers do not have a good command over new resuscitation technology, especially intubation techniques. Ventilation is the foundation stone of success in the resuscitation of a newborn. Tracheal intubation is the gold standard in establishing an effective airway, but because of technological and other reasons, such tracheal airway intubation is not easy to achieve. Therefore, finding a new, simpler operation to replace tracheal intubation for a positive pressure ventilation device, and methods to simplify resuscitation technology, to improve the effectiveness of neonatal resuscitation in hospitals at all levels, is an urgent challenge faced by China’s academicians in the perinatal field. Since2000, international guidelines and consensus on neonatal resuscitation recommend the use of the laryngeal mask airway (LMA) when bag-mask ventilation (BMV) is ineffective and/or tracheal intubation (ETI) is unsuccessful. There are many research papers published on the subject. LMA was designed in1981by the British anesthetist Dr. Archie Brain as a subglottic airway opening device. LMA can quickly establish the airway for effective ventilation within seconds in emergency situations.At present, there is very little material on the applications of the laryngeal mask and tracheal intubation in neonatal resuscitation. This study is about the feasibility, efficacy and safety of utilizing laryngeal mask airway (LMA) ventilation as compared to endotracheal intubation (ET) in neonatal resuscitation for moderately and severely asphyxiated neonates.[Objective]To study the feasibility, efficacy and safety of utilizing laryngeal mask airway (LMA) ventilation compared to endotracheal intubation (ET) in neonatal resuscitation for moderately and severely asphyxiated neonates.[Methods]1ObjectA prospective study of the use of LMA in neonatal resuscitation was conducted for about one and a half years (June2010-December2011) at the Shenzhen Maternal&Child Health Hospital, affiliated to Southern Medical University. Inclusion criteria for the68newborns selected were a gestational age≥34weeks, an expected birth weight >2.0kg, and the need for positive pressure ventilation with a heart rate<60beats per min (bpm) at birth after initial resuscitation measures (providing warmth, positioning, clearing the airway, drying and stimulation) over the first30s, or by the presence of persistent central cyanosis despite receiving supplementary oxygen. Exclusion criteria included still-births, severe prenatal depression (with Apgar score nearly0at1min after birth), major malformations of the respiratory system or cyanotic congenital heart disease.The study was approved by the institutional ethics committee and informed consent was obtained from parents.2GroupingTo avoid delays in starting resuscitation, neonates were quasi-randomised to the LMA (size-1LMA-ClassicTM The Laryngeal Mask Company Limited, UK) group or the ET group according to their date of birth as reported by Saugstad.The LMA was used on even dates (LMA group,36cases), and the ET on odd dates (ET group32cases).3ResuscitationThe standard LMA insertion technique described by Brain was used. The LMA was held in place and connected to a self-inflating bag for positive pressure ventilation. During resuscitation, positive pressure ventilation was given at40-60breaths per min with oxygen at a flow rate of6-8L/min.4Observation indexThe following data was collected during resuscitation:(1) Apgar score at1min and5mins after birth;(2) LMA insertion time, the rate of successful insertion at the first attempt, and the number of attempts required to insert the LMA successfully;(3) Successful resuscitation rate of both groups. Failure was defined as when LMA had to be replaced by ET for the LMA group, and as when the newborn could not recover after ET PPV for the ET group.(4) Resuscitation response time (the time period from starting LMA resuscitation to achieving an effective response), ventilation time (5) adverse effects during resuscitation (6) arterial blood gases, and blood sugar level before and after resuscitation from each group. 5Statistical analysisData was analyzed using SPSS13.0. Test of normality was used for continuous variables. Normally distributed data were reported as means and standard deviations. Skewed distribution data were analyzed after natural logarithmic transformation and reported as median and interquartile range. Independent t-tests were used for normally distributed data, and nonparametric tests for abnormally distributed data and nonparametric variables. Chi-square tests were used for categorical data, and exact probability tests were used for categorical data which was not suitable for chi-square test. P<0.05was considered as a statistically significant difference.[Results]1No significant difference was observed in Apgar scores at1min and5min between the two groups (p>0.05).2Rate of successful first insertion was94.4%with an average inserting time of (7.58±1.16)s for LMP group, while it was90.6%and (7.89±1.52)s for ET group.3Successful resuscitation rate of LMA group (86.11%) was slightly lower than ET group (96.88%), but there was no statistical difference (p>0.05).4Mean response time of the LMA group [(34.06±10.56)s] was slightly lower than the ET group [(41.38±27.19)s], also ventilation time of LMA group [(137.19±80.14)s] was slightly lower than the ET group [(171.09±84.28)s], but both showed no statistical differences (p>0.05).5There was no difference between the LMA and ET groups in arterial blood gas values, and glucose levels before and after resuscitation.6Adverse reactions found in LMA group including nausea (2cases) and abdominal distention (lcases), while those found in the ET group included laryngeal edema (lcases), pneumothorax (2cases), and respiratory tract bleeding (lcases). There was no other severe adverse effects (e.g., laryngospasms) in either group.There was no significant difference in the incidence of adverse effects between the two groups (8.33%vs12.5%, X2=0.319, P>0.05). 7PrognosisThe LMA Groups showed no deaths, with only2cases of mild hypoxic ischemic encephalopathy (HIE) and1case of moderate to severe HIE. The ET group had1case that of death,and2cases of moderate to severe HIE. All the HIE cases in both groups were cured.[Conclusions]LMA ventilation is much easier to operate, with its effectiveness no less than that of ET ventilation on resuscitation for moderate and severe asphyxiated cases. Infact it even seems safer. LMA ventilation can be a good substitute for ET ventilation, especially for those medical staffs who are unfamiliar with ET operation and primary hospital doctors in emergency cases. |
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