Airway control during interhospital transport may present enormous management difficulties, even for experienced personnel. The laryngeal mask airway is an airway management device that has been established as a safe reliable tool in adult and pediatric practice. We describe 2 cases of successful interhospital transfer of infants with congenital airway malformations with the use of the laryngeal mask airway, and we review the literature.
The laryngeal mask airway (LMA) is a supraglottic device developed by Dr Archie Brain in 1981.1 Since its introduction into clinical practice, the LMA has gained increasing popularity among medical and paramedical staff members, for anesthesia and resuscitation of adult and pediatric patients.2
For neonates, although education of personnel, competence, and use of this device remain low,3 the LMA has been used successfully for resuscitation,4,5 intrapulmonary administration of therapeutic agents,6,7 management of difficult airways,8 and respiratory support for prolonged periods.9 In addition, 2 previous reports showed that the LMA may be useful for neonatal transportation if other forms of airway management fail.10,11 We report the use of the LMA for 2 neonates during interhospital transfer, and we review the literature.
A male infant weighing 2.61 kg was born through elective caesarean section, performed because of polyhydramnios, at 36 weeks of gestation. Shortly after delivery, the patient developed signs of severe respiratory distress and required positive-pressure ventilation, but bag-and-mask ventilation was ineffective and tracheal intubation failed. External cardiac massage was performed and epinephrine and sodium bicarbonate were administered. Apgar scores were 3 and 3 at 1 and 5 minutes, respectively. Because temporary respiratory improvement was noted when the child crying, the diagnosis of choanal atresia was suspected. Therefore, an oral airway was positioned and bag-and-mask ventilation was initiated. Despite this attempt, ventilation of the patient remained unsatisfactory. Ten minutes after birth, the transport service was alerted by the referring physician and, on the basis of clinical and laboratory data (pH 7.03; arterial carbon dioxide pressure: 88 mm Hg; arterial oxygen pressure: 71 mm Hg; HCO3 concentration: 12 mmol/L), use of the LMA was suggested. A size 1 LMA was inserted, and effective ventilation was obtained. One hour later, at the time of transport team arrival, the infant was undergoing manual ventilation with the LMA, transcutaneous saturation was 98%, and the venous blood gas analysis indicated equilibration (pH 7.28; carbon dioxide pressure: 52 mm Hg; oxygen pressure: 54 mm Hg; HCO3 concentration: 21 mmol/L). Orotracheal intubation was performed by the transport team physician, and the patient was transferred to our hospital for additional treatment. The diagnosis of isolated choanal atresia was confirmed; the patient underwent surgical treatment, after which he was discharged in good clinical condition.
A female infant weighing 2.37 kg was born through emergency caesarean section, performed because of poor beat-to-beat variability, late decelerations, and meconium-stained amniotic fluid, at 41 weeks of gestation. The pregnancy had been complicated by intrauterine growth retardation and polyhydramnios. At birth, the infant presented with bradycardia (heart rate: 80–90 beats per minute), hypotonia, and respiratory distress associated with severe hypoplasia of the mandible (Fig 1). Resuscitation was initiated immediately (Apgar scores of 3 and 7 at 1 and 5 minutes, respectively) but, after nasal and oropharyngeal suction, both bag-and-mask ventilation and tracheal intubation failed. In addition, placement of a nasopharyngeal tube was unsuccessful. Therefore, a size 1 LMA was inserted at postnatal age of 5 minutes. This procedure allowed effective oxygenation and ventilation of the patient (pH 7.19; carbon dioxide pressure: 62 mm Hg; oxygen pressure: 179 mm Hg; HCO3 concentration: 24 mmol/L). The patient was referred to our institution at 20 minutes of age, for additional treatment. Eighty-five minutes later, after the arrival of the transport team, attempts were made to secure the infant's airway for transfer but tracheal intubation was impossible because of severe micrognathia and glossoptosis. In addition, an attempt at blind intubation through the LMA failed. Instead, the LMA was effective in allowing positive-pressure ventilation during the 3 intubation attempts. Because of the ease of LMA placement and the efficacy of positive-pressure ventilation, ground ambulance transfer (52 minutes) of the patient was successfully undertaken. Arterial blood gas analysis performed immediately before the transport indicated the following: pH 7.28; carbon dioxide pressure, 43 mm Hg; oxygen pressure, 244 mm Hg; HCO3 concentration, 21 mmol/L. No difficulties were encountered during the transfer. The clinical parameters were stable (heart rate: 124–132 beats per minute; respiratory rate: 52–60 breaths per minute; transcutaneous saturation: 94–98%; mean arterial blood pressure: 48–51 mm Hg). After the patient's arrival at the tertiary center, the previously alerted pediatric otorhinolaryngologist passed an endotracheal tube (size 3.5) over a fiber-optic bronchoscope and through the nose of the patient, in the operating room. The next day, the patient underwent a mandibular distraction intervention. The time of treatment was 4 weeks. Chest radiographs also showed 10 ribs with gap defects between the dorsal ossified and ventral cartilaginous segments, bilaterally. The genetic diagnosis was cerebrocostomandibular syndrome. The patient was discharged 2.5 months later, in good clinical condition.
Previously, 3 case reports (2 infants with type 3 laryngotracheoesophageal clefts and 1 infected neonate) highlighted the use of the LMA during interhospital transport.10,11 Airway control during interhospital transport may present enormous management difficulties, even for experienced personnel.12
The transport process begins with telephone communication between the referring physicians and the transport team personnel. The receiving center is responsible for providing referring physicians with any information that may enhance understanding of the patient's needs.12 In the first case, the suggestion for using the LMA was as a rescue device for ventilation of the patient in the period between the telephone call and the arrival of the transport team. Interestingly, the LMA was correctly positioned in the first attempt by a pediatrician inexperienced in its use, confirming the ease of placement by inexperienced personnel that was reported previously.2,4,5
Case 2 involved an infant who could not be intubated by either the referring physicians or the transport team personnel, because of a severe congenital airway malformation. In this situation, the LMA allowed effective ventilation and oxygenation and permitted transfer to a safe setting.
In the literature, 5 cases (including these 2 cases) of LMA use during neonatal transport have been reported.10,11 Interestingly, in 4 of the 5 cases, the history was positive for polyhydramnios, which suggests that accurate prenatal diagnoses could facilitate the prediction of difficult airways in this group of patients. For these treated patients, the gestational age was ≥35 weeks and the birth weight was ≥2.37 kg. However, the LMA is effective in the resuscitation of smaller infants.5,6 Four patients required neonatal resuscitation, and the LMA provided an effective airway in a wide range of postnatal times (5 minutes to 24 hours). For all 5 patients, LMA use was determined by the failure of conventional modes of ventilation (facial mask and tracheal intubation). The size 1 LMA was effective in all cases; for 1 patient, size 2 LMA insertion failed. In 3 of 5 cases, no sedative and/or paralytic drugs were used for LMA insertion and placement, which suggests acceptance of this device for relatively long periods of time.
The LMA was positioned at the referral hospital in 4 cases; in 1 case, the LMA was positioned during interhospital helicopter transport because of an unexpected apneic episode that did not respond to stimulation and bag-and-mask ventilation.10 In 1 case, the LMA was used as a rescue device for 90 minutes, from the time of birth to the arrival of the transport team. These cases demonstrate that the LMA may play an important role in airway management in all phases of the transport process, ie, during stabilization at the referral hospital (before the arrival of the transport team), during the transfer, and after arrival at the tertiary center.
The duration of LMA use ranged from 5 minutes to 4 hours. No complications related to its use were reported, which suggests the safety of this device for both inexperienced and skilled personnel.2 Different transport vehicles were used for the transportation of these patients; the LMA was always useful, particularly in situations in which access to the patient's airway was limited, such as in a helicopter.10 Placement of the LMA does not require manipulation of the patient's head, neck and jaw, is not influenced by anatomic factors, and does not require laryngoscopy.2 All of these characteristics could be life-saving in the treatment of sick neonates, particularly during interhospital transport, which is considered a dangerous phase in the care of newborns.
Airway congenital malformations were reported for 4 patients, which suggests that the role of the LMA is particularly important for this group of neonates; however, the use of this device should also be considered for patients with normal airways.10 The LMA has been recommended by the American Heart Association and the European Resuscitation Council for use in adult resuscitation.13 In road traffic accidents, paramedics have used the LMA to provide emergency airway control for victims when limited access to the patient has made laryngoscopy impossible.2
Recently published International Guidelines for Neonatal Resuscitation suggested that “the LMA may serve as an effective alternative for establishing an airway if bag-mask ventilation is ineffective or attempts at intubation have failed.”14(p9) However, routine use of the LMA cannot be recommended at this time.14,15
Standard equipment listed for interhospital care of perinatal patients includes a variety of devices, such as tracheal tubes, facial masks, and oral airways.12,16 We recommend that the list should include the LMA, for situations in which airway management is difficult or cannot be achieved with a facial mask or tracheal tube. Rescue personnel must be trained in the use of the LMA before this modality is added to all protocols.
- Accepted September 13, 2004.
- Reprint requests to (D.T.) Pediatric Department, University of Padova, Via Giustiniani 3, 35128 Padova, Italy. E-mail:
No conflict of interest declared.
- ↵Brain AI. The laryngeal mask: a new concept in airway management. Br J Anaesth.1983;55 :801– 805
- ↵Brimacombe J. Airway rescue and drug delivery in an 800 g neonate with the laryngeal mask airway. Paediatr Anaesth.1999;9 :178– 179
- ↵American Academy of Pediatrics. Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients. Elk Grove Village, IL: American Academy of Pediatrics; 1999
- ↵American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology.2003;98 :1269– 1277
- ↵Niermeyer S, Kattwinkel J, Van Reempts P, et al. International Guidelines for Neonatal Resuscitation: an excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Pediatrics.2000;106(3) . Available at: www.pediatrics.org/cgi/content/full/106/3/e29
- ↵Kattwinkel J, Niermeyer S, Nadkarni V, et al. An advisory statement from the Pediatric Working Group of the International Liason Committee on Resuscitation. Pediatrics.1999;103(4) . Available at: www.pediatrics.org/cgi/content/full/103/4/e56
- ↵Insoft RM. Neonatal transport. In: Cloherty JP, Eichenwald EC, Stark AR. Manual of Neonatal Care. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2004:151–157
- Copyright © 2005 by the American Academy of Pediatrics