Laryngeal intubations?

Gompers, BSN, RN · Mar 18, 2006

Our unit is going to start doing this and it sounds scary! Anyone else do this?

I don't know what you mean. Can you explain?

Editorial Team / Admin · Mar 18, 2006

I've never heard of a laryngeal intubation, dawngloves. Can you please explain the term?

dawngloves, BSN, RN · Mar 18, 2006

Here is an article that touches on it. I don't know much about it it, but I worry about long term effect on the airway and palate. maybe it would be good for term mec asp kids?

http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijeicm/vol2n1/lma.xml

Picture of tube here:

http://www.int.lmanv.com/anelmastor.asp

Editorial Team / Admin · Mar 18, 2006

I understand. You are referring to an LMA airway. This is not intubation.

Our anesthesia department utilizes these. They are used for short procedures, no need for intubation, difficult anatomy, injuries (C-spine).

dawngloves, BSN, RN · Mar 18, 2006

I hear they are used in the OR. We are looking to utilze them in order to decrease tracheomalacia. I can't see doing this on micro.

Gompers, BSN, RN · Mar 18, 2006

I guess I just don't understand the need for this. This is just to secure the airway, right? Babies usually don't have obstructive apnea, so I don't understand the need for this device in the airway. Now, if this thing is hooked up to a vent, I guess I can see that - but then wouldn't the baby be getting a lot of air into the stomach as well, since the LMA is only in the back of the throat?

Are they making size 0 or 00 ones now? Because the article says that the size 1 tube is for babies >2.5kg so tht really narrows down the number of patients we can use it on. If it's a bad meconium - what is the point of an LMA? We need to traditionally intubate for those kids so we can deep suction the lungs.

I'm sorry to be so confused, I just don't see the point of this device in neonates I suppose.

I totally get why this scares you! Scares me too.

Love_2_Learn · Mar 18, 2006

I attended a nursing conference last year where Dr. Jay Goldsmith spoke about upcoming changes in the NRP (Neonatal Resuscitation Program) which will occur in May of this year when the new NRP books are ready for sale. He is on the NRP committee responsible for making changes to NRP and is a great speaker.

Among many things, he mentioned the laryngeal mask airway in his talk. He said NRP will suggest their use to maintain an open airway when intubation is difficult or not possible during a neonatal resuscitation. In this case it's not meant to be long term, does not require a laryngoscope, and is very easy to learn to place in the baby's mouth/throat area. I believe he also said they are meant more for use with the larger preemies and term babies, not for the micropreemies.

There are many changes coming in the new NRP guidelines. You can check them out by going to:

http://www.aap.org/

then scroll down near the bottom left of the page where you see:

Browse AAP.org

and the second item under that is Neonatal Resuscitation Program, click on that and you be taken to a page where you choose:

Life Support Programs

where you will choose the Neonatal Resuscitation Program, and click on it.

On that next page you will see:

What's New

where the second and third links under that are in Adobe format and are absolutely the most wonderful resources to know what's coming ahead for us all.

The first one to look at is called: NRP Instructor Update Newsletter

Fall/Winter 2005

The second on to look at is called: Summary of Major Changes to the

Guidelines

The second one is actually included in the first (Newsletter) one.

You can also google or search for laryngeal mask airway on your computer to see what they look like...

I don't think they are meant to be used with ventillators though... I'm not certain about that...

:twocents: :wink2:

dawngloves, BSN, RN · Mar 18, 2006

I thought it would be better used for mec asp kids. But I think I heard that you can't suction with them? And what about meds given down the tube during a code? Wouldn't they go in the stomach?

Gompers, BSN, RN · Mar 18, 2006

I thought it would be better used for mec asp kids. But I think I heard that you can't suction with them? And what about meds given down the tube during a code? Wouldn't they go in the stomach?

Exactly why I'm thinking this wouldn't be a good idea for those kids. I can't think of ANY kid this would be a good idea for...

Preemies - it would probably be too big, plus many will need surfactant, which you need an ETT for anyways. Same with Epi.

Mec asp - if they are screaming their lungs out, it's too late to suction and no need for airway protection. If they're limp and nonresponsive, then they will need deep tracheal suctioning - so again, need a real ETT for this.

Full term code - these kids usually need Epi down the ETT, so the LMA wouldn't help us there either.

I will go read all the new NRP stuff when I have time, as maybe this stuff is explained...

Love_2_Learn · Mar 18, 2006

Those are good questions DawnGloves. My understanding is that the laryngeal mask airway is simply for use in obtaining an emergency airway so you can give bag and mask ventillation (because without ventillation the heart rate will not rise...) I don't think you can give meds or surfactant through them or suction meconium through them. You see, the thing fits in the back of the throat and has a tube on the other end of it for the PPV to be done. The part in the mouth is sort of "V" shaped with a thin cuff around it (similar to the puffy cuff around regular masks we use for bag & mask PPV). It's pretty cool looking. I think a physician in the United Kingdom invented it about 25 years ago.

If you go to the link I mentioned in my above post, you will see (if you are not already aware) that changes are coming for epinephrine (IV through a quickly placed UVC) will be the preferred route in the delivery room, and IV for all other babies (at the same dosage as we've been giving 0.01 to 0.03 mg/kg); and if it must be given through the ET tube the dosage is significantly increased (up to 0.1 mg/kg). (We may need to give an ET dose one time while the UVC or IV is being placed.) And as far as meconium goes, it will be no longer recommended that all meconium-stained babies routinely receive intrapartum suctioning (i.e. before delivery of the shoulders); however other recommendations about post delivery neonatal suctioning will remain unchanged (i.e. intubate and suction babies who are not classified as "vigorous" as we've been doing for the past few years.) There are more changes too, too many to mention here.

It's really enough to make my head spin!!

Check out an example of a laryngeal mask airway at: http://www.airwaycarnival.com/LMA.htm

Check out the information about NRP changes for 2006 at:

http://www.aap.org/

and follow the links: Browse AAP.org then NRP Life Support Program then What's New then NRP Instructor Update Newsletter, Fall/Winter 2005

Jolie, BSN · Mar 18, 2006

I thought it would be better used for mec asp kids. But I think I heard that you can't suction with them? And what about meds given down the tube during a code? Wouldn't they go in the stomach?

It is my understanding that this is not intended to replace standard intubations in neonatal resuscitation, just to provide a temporary alternative in cases where intubation is especially difficult, like a child with anatomical abnormalities. If such a child required resuscitation in the DR, this technique could be used to temporarily secure an airway. Code drugs would have to be given by other means such as a UVC or PIV. Tracheal suctioning could be accomplished by temporarily removing the mask, visualizing the cords, suctioning directly, then replacing the mask if ventilation is needed.

Once the baby is stabilized in the DR, and transferred to the NICU, other airway options would be considered.

I think this could also be useful in situations where there is no one skilled in neonatal intubations present at a delivery, such as out of hospital births, deliveries in the ER, and small, rural hospitals with limited specialized staff.