Laryngeal mask airway for surfactant administration in neonates: a practical guide

Bysatrorerku
If using a “Y” adapter, additional equipment is need and includes:
  1. 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
  2. ScissorsNecessary to cut the feeding tube to the proper length to administer surfactant to the distal end of the body of the LMA
  3. Tape measureNecessary to measure the proper length to cut the feeding tube
  4. 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. Bubble CPAP Setup
Ventilation device
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.
  1. T-piece resuscitator
  2. 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.
Additional equipment
  1. Suction
  2. Stethoscope
Rescue Equipment
Appropriately sized equipment should be readily available to convert to bag-mask ventilation or intubation if significant desaturation or bradycardia were to occur.
  1. Mask
  2. Intubation supplies
It is recommended to create an “LMA Surfactant Supply Kit” containing the supplies and procedure guidelines (Figure 4).
Preparation
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.
Procedure
A flowchart of the procedure is shown in Figure 5.
Preparation
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).
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.
 

0

0