The tennis serve is one of the most challenging skills for beginners to learn. It requires complex coordination, timing, and speed. The server must strike a ball rising above the head with enough force from the baseline to clear the net and have it land in a small box. However, move the novice closer to the net, and serving is suddenly much easier. Shortening the distance to the target increases effectiveness. Like the tennis serve, effective face mask ventilation of a neonate is a challenging skill to master. Inserting a supraglottic airway (SA) shortens the distance to the glottis, improving the success of positive pressure ventilation (PPV).
In this edition of Pediatrics, Yamada et al1 report the results of a systematic review comparing ventilation using SAs to face masks during the resuscitation of 1823 newborns >34 weeks gestational age and >1.5kg birth weight. The included studies were conducted in various practice settings with many types of clinicians. They found that infants who received positive pressure with an SA were more likely to improve. Specifically, the duration of PPV and time until heart rate reached >100 beats per minute was shorter for infants in the SA group. SAs were added to the Neonatal Resuscitation Program (NRP) in 2015 as an alternative to endotracheal intubation in scenarios in which the clinician could not effectively ventilate2 using a face mask. In the 2020 NRP update, SAs were listed on the same line as endotracheal intubation for infants with persistent bradycardia after initial resuscitative measures.3 Now, the question is: should SAs be the first-line approach for PPV in the NRP?
Before the face mask goes the way of the wooden tennis racket (which is no longer used by most tennis players today), a careful examination of this study is warranted. The authors found improvements in proxy measures of successful neonatal resuscitation. What about other outcomes significant to patients and families? There were no differences in chest compressions, epinephrine use, subsequent NICU admission, or survival to hospital discharge between the 2 groups. There were insufficient data to assess neurodevelopmental impairment at 18 months, and the study did not address other neurologic morbidities. Extremely low birth weight neonates were excluded as there was no appropriate SA size for use in these patients. In addition, as the authors acknowledge, there was a substantial risk of bias in the included studies because personnel delivering PPV in the delivery room and assessors could not be blinded to group assignments.
Despite these limitations, the results of the meta-analysis are compelling. In scenarios in which seconds matter, infants in the SA group got better faster. The duration of PPV and the time to heart rate reaching >100 was shorter in the SA group. We were particularly impressed by the ability of a variety of clinicians of different backgrounds to safely and effectively perform PPV using SAs. Previous work has revealed that NRP clinicians struggled with SA insertion in simulated scenarios4 ; however, Yamada et al found remarkable success with SAs placed by nurses, midwives, pediatricians, and anesthesiologists in the included studies with little need for extensive training. Further investigation should determine the durability of training in neonatal SA placement. However, the presented data are promising for the efficacy of SA use for initial PPV in neonatal resuscitation across a wide variety of settings.
As a caveat, the placement of an SA is more invasive than mask ventilation and may cause trauma. One study of pediatric SA placement under ideal operating room conditions found a 4% incidence of complications and a 1% incidence of failure of the SA.5 Inappropriate placement and overinflation of the SA may lead to complications such as glottic trauma, gastric insufflation, and nerve injury. Although these events are rare, they need to be considered in the context of widespread use. In addition, SAs come in many shapes and sizes with various designs. Some SA cuffs require inflation, whereas others do not. The design of the SA is likely to be associated with the risk of complications and ease of insertion; unfortunately, this analysis could not draw conclusions regarding SA design. Cost is another essential consideration for transitioning to SAs as a primary resuscitation tool. If PPV is required in 5% of all births, what is the cost of stocking every resuscitation room throughout the world with an SA? A differential cost analysis is imperative to understand the financial impact of using an SA instead of a face mask for PPV.
Yamada and colleagues have demonstrated that SAs can help reduce the distance to the airway and improve the success of PPV. We applaud this work in evaluating the best airway management practices in the delivery room. We will undoubtedly consider reaching for an SA next time we care for a term or near-term neonate who needs PPV but will do so cautiously. Before we abandon face mask ventilation completely, we encourage future studies to examine complications and costs. It just might be that serving from the net may be the way to go every time.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2022-056568.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: Dr Fiadjoe discloses grant funding from the Anesthesia Patient Safety Foundation unrelated to this editorial. The other authors have indicated they have no potential conflicts of interest relevant to this article to disclose.