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Birth asphyxia is a leading cause of neonatal death. Positive pressure ventilation is the key to resuscitation. This is usually delivered by mask, although mask technique can present challenges in getting a good seal. Intubation is the procedure of choice if mask ventilation fails, however it presents difficulties within itself, with success rates being operator dependent and varying from 24% in residents to 86% in consultants(1)

Can LMA’s reduce the need for intubation? Can they be used in place of a face mask? Guidelines recommend laryngeal mask airways if positive pressure ventilation fails with face mask and intubation is not a feasible option.

The study reviewed here, by Pejovic et al(2), looked specifically at low income countries, where no advanced airway is performed. The aim was to look at the effect of LMA’s being used by ‘non-doctors’, (in this case midwives) and assess mortality and morbidity. It compared the LMA to a standard round face mask.

This has implications for all countries and not just low income countries. It has potential applications in the rural sector where doctors are not always available.

Study design

Single Site
Superiority Trial

n= 1163

What they did:
Compared LMA Igel size 1 with round size 1 Leardel Mask

There was one day of training provided for the midwives in this study.


Primary Outcome: Death within 7 days of admission to NICU, with moderate-severe hypoxic ischaemic encephalopathy

Secondary Outcomes: Safety of LMA as used by midwives, need for advanced resuscitation and early neonatal death (<7days)


“…..the effectiveness and safety of the LMA in neonatal resuscitation conducted by midwives in a low income country showed the LMA to be safe in the hands of midwives, but to confer no benefit over the facemark with respect to the composite of early neonatal death or moderate-to-severe hypoxic-ischemic encephalopathy”

We need to remember that this was a superiority, not inferiority trial.

What I take from this is that what we have been doing, ie using LMAs continues to be safe in neonatal resuscitation.


  1. O’Donnell CPF, Kamlin COF, Davis PG, Morley CJ. Endotracheal intubation attempts during neonatal resuscitation: success rates, duration, and adverse effects. Pediatrics 2006;117(1):e16e21.
  2. Pejovic N et al. A Randomized Trial of Laryngeal Mask Airway in Neonatal Resuscitation. N Engl J Med November 26 2020; 383:2138-2147

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