Although endotracheal tubes remain the most common airway device in neonates undergoing anesthesia, a recent retrospective study suggests that supraglottic airway use in this population may not be associated with major airway-related complications. The cohort study of supraglottic airway devices in neonates demonstrated a 97% success rate for airway maintenance.
According to the investigators, more studies are needed to establish robust success rates for various supraglottic airway devices, but this early analysis should alert clinicians to their possible expanded utility in the smallest of patients.
“Given a failure rate of only 3%, we believe it’s important to increase clinician awareness of the supraglottic airway as a rescue device option or potentially as a primary airway device,” said John Hajduk, CCRP, Clinical Research Coordinator II, Department of Pediatric Anesthesiology at the Ann & Robert H. Lurie Children’s Hospital, in Chicago.
As Mr. Hajduk reported, the use of a supraglottic airway device as a primary airway device is rare in infants. A survey of practice patterns of pediatric anesthesiologists found that approximately 40% rarely or never use laryngeal masks in infants less than 12 months of age, versus 8% in those 1 to 3 years old, Mr. Hajduk said. In neonates, laryngeal mask use is estimated to be less common than in infants, and even less common among nonpediatric specialized anesthesiologists.
“Clinicians disfavor supraglottic airway use with decreasing patient age, and many institutions mandate endotracheal intubation below certain ages,” he explained.
Despite these mandates, meta-analyses in children and recent trials in infants suggest there are safety advantages of supraglottic airways over endotracheal tubes.
“The data indicate that endotracheal tubes are clearly the most common airway device in neonates,” Mr. Hajduk said, “but these are not without airway morbidity.” Analyses of neonates and infants also have shown laryngeal and tracheal trauma following intubation to be the leading cause of stridor, and there are case reports of other invasive airway morbidity.
In addition, a recent meta-analysis of respiratory complications in children found fewer intraoperative complications with supraglottic airway devices than with tracheal intubation, including approximately one-third less desaturation and laryngospasm (Paediatr Anaesth2014;24:1088-1098). The same study showed significantly fewer postoperative complications as well, including sore throat, bronchospasm and aspiration. However, the youngest patient was 6 months old, and neonatal data were not analyzed.
A separate analysis of 11,910 pediatric anesthesia cases found a failure rate of less than 1% (0.86%) using the LMA Unique (Teleflex), but only 68 of the total group were under 6 months old. Although this subgroup had a failure rate of only 2.94%, according to Mr. Hajduk, the number of neonate cases is too small to draw definitive conclusions.
“Reports of supraglottic airway use in neonates are largely limited to case reports and neonatal resuscitation, but even the literature with resuscitation suggests that neonates who receive supraglottic airway do better than intubation,” he said. “We felt the need to find more evidence to show just how effective this method is in neonates undergoing anesthesia.”
Following IRB approval, Mr. Hajduk and his colleagues screened anesthetic records of 3,500 neonates (≤30 days old) for attempted supraglottic airway placement intended for primary airway maintenance. The investigators included only normal airways in the study. Patients were excluded if there was a history of difficult laryngoscopy; a suspected/diagnosed syndrome with altered airway or oral morphology, such as Pierre Robin syndrome or cleft palate; or a diagnosis affecting airway posturing (e.g., opisthotonus, use of c-spine collar).
The investigators extracted the following data from the records: patient characteristics, procedural data, periprocedural adverse events (AEs) classified as minor or major, device failure and discharge location. The primary outcome measure was the composite incidence of device failure, with major and minor perioperative respiratory AEs. Minor AEs included oxygen desaturation of less than 90%, airway obstruction and new-onset stridor, while laryngospasm, bronchospasm and aspiration were classified as major AEs (Table).
|Table. Outcomes Following Placement of Supraglottic Airway Devices|
|Failed SGA Placements – Total||2/65 placements; 3.1%
(95% CI, 0.2%-11.7%)
|Intraoperative Inadequate Seal, to ETT||1/64 patients; 1.6%
(95% CI, <0.1%-9.1%)
|PRAEs with SGA as primary device|
|Major||0/64 patients; 0.0% (95% CI, 0.0%-5.6%)|
|Minor||1/64 patients; 1.6% (95% CI, <0.1%-9.14%)|
|Unanticipated ICU Due to PRAE||0/64 patients; 0.0%
(95% CI, 0.0%-5.6%)
|ETT, endotracheal tube; PRAE, perioperative respiratory adverse event; SGA, supraglottic airway devices|
As Mr. Hajduk reported at the 2017 annual meeting of the Society of Airway Management, supraglottic airway insertion was successful 97% of the time (63/65 attempts; 95% CI, 89%-99%). In addition, anesthesia was uneventfully provided without perioperative respiratory AEs or device failure in 94% of patients (60/64 cases; 95% CI, 85%-98%). These cases lasted a median of 43 minutes (interquartile range, 19-65 minutes) and included 10 emergent cases. Maximum anesthesia duration was 147 minutes. The devices used in the study were the LMA Supreme (Teleflex) in three patients, LMA Unique in 21 patients and air-Q (Mercury Medical) in the rest of the patients.
Of the four AEs, Mr. Hajduk said, two were supraglottic airway failures at placement, one was a conversion to endotracheal tube, and there was one episode of desaturations in a patient with known respiratory comorbidities. Major perioperative respiratory AEs or unplanned ICU admissions did not occur, the investigators noted.
According to Mr. Hajduk, this is the first cohort study to examine routine supraglottic airway use in neonates, but future prospective studies in large cohorts are required to address the shortcomings of this relatively small retrospective study to determine the predictors of safety and efficacy in this high-risk population. In the meantime, the researchers will continue to gather data on difficult airway management. “This is very preliminary data,” he said.