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Three Part Question

In [paediatric cardiopulmonary arrest] are [supraglottic airway devices(SAD)] adequate for [oxygenating and ventilating]?

Clinical Scenario

A two year old has a witnessed cardiopulmonary arrest whilst in your Emergency Department. You are able to ventilate the child using a bag valve mask (BVM) and oral pharyngeal airway, but notice his stomach is becoming inflated. In cardiac arrest in adults you know that a LMA or iGel is now the advised airway to use (ALS guidelines 2011), but you wonder if this could apply to children as well.

Search Strategy

MEDLINE (1950-present)and EMBASE (1980-present)
[(exp ventilation) AND (exp ped* OR paed* OR child) AND (exp arrest)]
LIMIT: English

Search Outcome

327 papers, 6 of which were relevant. A further two papers were found from the reference of one of the original search articles.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Moreto A et al 2012 UK	Case report of a 14 day old female with Pierre Robin sequence who needed a tracheotomy	Case report	I-gel used to successfully ventilate the child where intubation was not possible	Successful surgery and the child was discharged from ICU four days later	One case and child had a known factor for a difficult airway
Beringer R.M. et al 2011 UK	120 children (ASA1-2) undergoing routine surgery were ventilated using an I-gel. Aged 4 months-13 years and weight 7-35kg.	Prospective observational study	The I-gel is effective in oxygenating and ventilating children with respiratory arrest and may be a simple alternative to securing an airway. One child regurgitated without aspirating. Other complications and side effects were infrequent.	110 I-gels inserted in 1st attempt, 8 in 2nd attempt and 1 in 3rd attempt (one failed). Median (IQR [range]) insertion time was 14 (9–16 [6–200]) s. Median (IQR [range]) leak pressure was 20 (16–26 [8–30]) cmH2O	All devices inserted by an experienced anaesthesiologist. All health ASA 1-2 children with normal airways. Inserted in controlled theatre environment.
Blevin AE et al 2009 UK	99 anaesthetised children were ventilated by paediatric nurses using facemask and OPA and LMA	Prospective	LMA may represent a useful second line option for first reponders in paediatric cardiopulmonary arrest	Successful ventilation in 74 of cases with the LMA and 76 (77%) with facemask and OPA (p = 0.89). Median time to first breath was longer for the laryngeal mask airway (48 (39-65 [8-149])) s than the facemask/airway (35 (25-53 [14-120]) s; p <0.0001). In 10 cases the lungs were ventilated using the LMA but not using the facemask/OPA	Nurses were not taught how to use the device before using it
Boyle M et al 2010 Australia	A literature search using MEDLINE, EMBASE, Meditext, Cochrane and Scopus. From January 1996 – January 2010	Literature review	BVM is considered the best method for ventilating children and neonates	Many methods were used to assess adequate ventilation, but there is currently no consensus defining successful ventilation.	Only searched articles in English in electronic databases
Chen L et al 2008 USA	52 emergency medical practitioners were given a 2 hour teaching session on LMAs and ETTs. They were then presented with a arrest scenario (SimBaby) and assigned to groups to use either ETT or LMA first, then repeat the scenario with the other device.	Prospective	The use of laryngeal mask airway, compared with endotracheal tubes, led to more rapid establishment of effective ventilation and fewer complications when performed by prehospital providers.	The mean ± SD length of time to effective ventilation was 46 seconds when using endotracheal tubes and 23 seconds when using LMA. Total number of misplacement in the ETT group was 34%, compared with 9.5% in the LMA group.	There are several characteristics of the SimBaby that may not reflect reality. Specifically, the scenarios did not include airway trauma, vomiting, and airway secretions, which often occur in clinical situations. The study can record only a subset of complications that result from the use of ETTs and LMA
Guyette F.X et al 2007 USA	Paramedic students given a 1 hour training session on paediatric LMAs and BVM then performed airway management on simulator mannequins	Prospective	Prehospital providers were able to insert and successfully ventilate a simulated patient in respiratory arrest using an LMA after instruction. BVM is a quicker method for first ventilation	All subjects successfully ventilated the mannequins with both techniques. Median time from the start of the scenario to BVM ventilation was 4 seconds, and the median for LMA ventilation was 30 seconds. Tidal volumes were significantly greater with BVM ventilation (5.07 mL/kg) than with LMA ventilation (2.88 mL/kg) All inserted the LMAs successfully on the 1st attempt	There was a lot of air leakage using the LMA which was thought to be due to the mannequin being made of plastic and a problem using a simulator.
Rechner JA et al 2007 UK	60 children aged 6months to 8 years with ASA 1-2 had their airway controlled by 19 experienced critical care nurses	Prospective	Nurses trained in the insertion of LMAs can ventilate children better than using face mask, but the time taken to the first breath is longer using LMA	Successful ventilation was achieved via the LMA in 82% of children compared with 70% using facemask ventilation. Median time to first successful breath was 39 s for the LMA and 25 s for the facemask.	Excluded children with a difficult anticipated airway. Anaesthetised children do not pose the same challenges a child with on-going CPR does e.g. chest compressions. Infants under the age of 6 months were excluded.
Gausche M et al 2000 USA	830 patients aged 12 and under and estimated to weigh less than 40kg who required airway support	Prospective	An addition of endotracheal intubation to a paramedic who can already use a BVM did not improve survival or neurological outcome	There was no significant difference in survival between the BVM group (123/404 [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.61-1.11) or in the rate of achieving a good neurological outcome (BVM, 92/404 [23%] vs ETI, 85/416 [20%]) (OR, 0.87; 95% CI, 0.62-1.22).	Study investigators were not blinded to the groups. The study was conducted in urban/suburban so may not be valid for rural transport times.

Comment(s)

No paper looks specifically at using a SAD in a paediatric arrest, all the cases have been in mannequins or in anaesthetised children, simulating arrest. Hypoxia, which is often the cause, is a very important factor to overcome in paediatric arrest. By using a SAD one can undertake uninterrupted chest compressions and ventilation. The comparison with BVM and intubation in the prehospital setting shows that neurological outcome/survival is not significantly different between the two groups. Using a SAD may not be worth doing as it takes time to insert, meaning there is no ventilation in that time. However, in children with difficult airways who intubation poses a problem, it is worth bearing in mind the use of a SAD. Over time the effectiveness of BVM decreases, hence a more definitive airway should always be planned.

Clinical Bottom Line

A bag valve mask with oropharyngeal airway should be used initially to oxygenate and ventilate a child in cardiopulmonary arrest. A supraglottic airway should be considered in children with a difficult airway or if there is going to be delay in establishing a definitive airway (endotracheal intubation). SAD – supraglottic airway device LMA – laryngeal mask airway OPA – oropharyngeal airway BVM – bag-valve-mask ALS – advanced life support

References

1. Moreto A., Lobo M., Cobrado L., Teresa B. Pierre Robin sequence urgent tracheotomy: Case report British Journal of Anaesthesia March 2012, vol./is. 108/(ii302-ii303), 0007-0912 (March 2012)
2. R. M. Beringer, F. Kelly, T. M. Cook, J. Nolan, R. Hardy, T. Simpson, M. C. White A cohort evaluation of the paediatric i-gel™ airway during anaesthesia in 120 children Anaesthesia Volume 66, Issue 12, pages 1121–1126, December 2011
3. Blevin AE, McDouall SF, Rechner JA, Saunders TA, Barber VS, Young JD, Mason DG A comparison of the laryngeal mask airway with the facemask and oropharyngeal airway for manual ventilation by first responders in children. Anaesthesia December 2009, vol./is. 64/12(1312-6), 0003-2409;1365-2044 (2009 Dec)
4. Malcolm B, Flavell E. Which is more effective for ventilation in the prehospital setting during cardiopulmonary resuscitation, the laryngeal mask airway or the bag-valve-mask? - A review of the literature Journal of Emergency Primary Health Care Vol. 8: Iss. 3, Article 2
5. Chen L.,Hsiao A.L Randomized trial of endotracheal tube versus laryngeal mask airway in simulated prehospital pediatric arrest Pediatrics vol./is. 122/2(e294-297), 1098-4275 (Aug 2008)
6. Guyette FX,Roth KR,LaCovey DC,Rittenberger JC Feasibility of laryngeal mask airway use by prehospital personnel in simulated pediatric respiratory arrest Prehospital Emergency Care 04-06 2007, vol./is. 11/2(245-9), 1090-3127;1090-3127 (2007 Apr-Jun)
7. Rechner J.A., Loach V.J., Ali M.T., Barber V.S., Young J.D., Mason D.G A comparison of the laryngeal mask airway with facemask and oropharyngeal airway for manual ventilation by critical care nurses in children Anaesthesia August 2007, vol./is. 62/8(790-795), 0003-2409;1365-2044 (August 2007)
8. Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, Poore PD, McCollough MD, Henderson DP, Pratt FD, Seidel JS. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000 Feb 9;283(6):783-90. Erratum in: JAMA 2000 Jun 28;283(24):3204