The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. BAS is supported by the Oklahoma Shared Clinical and Translational Resources (U54GM104938) with an Institutional Development Award (IDeA) from the National Institute of General Medical Sciences.

All methods described here have been approved by the Institutional Review Board of the University of Oklahoma Health Sciences Center.
1. Placing a laryngeal mask
<ol>
	<li>Select appropriately sized SGA (newborn size 1 [2-5 kg]).</li>
	<li>Open the SGA. Remove the pack that holds the device.</li>
	<li>Open the pack. Transfer the SGA to the lid of the pack.</li>
	<li>Holding the integral bite block, apply a thin coat of lubricant to the back, sides, and the front of the SGA.
	<ol>
		<li>Check for boluses of lubricant and remove them if necessary.</li>
		<li>Take care to avoid contact with the cuff of the device.</li>
	</ol>
	</li>
	<li>Inspect the device carefully.
	<ol>
		<li>Check for foreign bodies or a bolus of lubricant obstructing the distal opening, and return the SGA into the cage pack.</li>
	</ol>
	</li>
	<li>Always wear gloves.</li>
	<li>Decompress the stomach with an orogastric tube as needed.</li>
	<li>Remove the SGA from the container.</li>
	<li>Hold the lubricated SGA firmly.</li>
	<li>Stand at the baby&#39;s head. Position the device such that the cuff outlet is facing the chin of the baby. Ensure that the baby is in the &#39;sniffing&#39; position with the head extended and the neck flexed. Gently open the mouth and press down on the chin before proceeding.</li>
	<li>Press the leading soft tip into the mouth against the baby&#39;s hard palate on the top of the baby&#39;s tongue. Maintain pressure against the palate.
	<ol>
		<li>Advance the device inward to follow the contour of the mouth and palate with a continuous but gentle slide until resistance is felt.</li>
		<li>Arrange the tip of the airway into the upper esophagus, positioning the cuff against the laryngeal framework.</li>
	</ol>
	</li>
</ol>
2. Confirming correct placement
<ol>
	<li>Attach the carbon dioxide (CO2) detector and connect it to the PPV device.</li>
	<li>After the correct placement, ensure that there is a bilateral chest movement with ventilation and hear equal breath sounds.</li>
	<li>If this intervention is successful, notice an increase in heart rate and oxygen saturation.</li>
	<li>By the time of providing 8-10 breaths, ensure that the CO2 detector turns yellow as it detects exhaled CO2.</li>
</ol>
3. Anchoring the laryngeal mask
<ol>
	<li>Secure the SGA down from maxilla to maxilla with tape.</li>
	<li>Monitor heart rate, oxygen saturation, breathing, and muscle tone. The newborn can cry and make sounds with the SGA in place.</li>
</ol>
4. Removing the laryngeal mask
<ol>
	<li>If one decides to remove the laryngeal mask, use bulb suction or suction catheter to remove secretions from the mouth and throat.</li>
	<li>Then, remove the SGA device.</li>
	<li>Monitor heart rate, breathing, and oxygen saturation.</li>
</ol>

<ol><li>Moshiro, R., Mdoe, P., Perlman, J. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+global+view+of+neonatal+asphyxia+and+resuscitation%5BTitle%5D)+AND+%22Frontiers+in+Pediatrics%22%5BJournal%5D)">A global view of neonatal asphyxia and resuscitation.</a> Frontiers in Pediatrics. 7, 489(2019).</li>
<li>McGuire, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Perinatal+asphyxia%5BTitle%5D)+AND+%22BMJ+Clinical+Evidence%22%5BJournal%5D)">Perinatal asphyxia.</a> BMJ Clinical Evidence. 2007, 320(2007).</li>
<li>Gillam-Krakauer, M., Gowen, C. W. Jr <a target="_blank" href="http://scholar.google.com/scholar?hl=en&safe=off&q=author%3aGillam-Krakauer%2C+M+%22Birth+Asphyxia%22">Birth Asphyxia</a>. , StatPearls Publishing LLC, Treasure Island, Florida. (2023).</li>
<li>Miniño, A. M., Heron, M. P., Smith, B. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Deaths%3A+preliminary+data+for+2004%5BTitle%5D)+AND+%22National+Vital+Scientific+Reports%22%5BJournal%5D)">Deaths: preliminary data for 2004.</a> National Vital Scientific Reports. 54, 19(2006).</li>
<li>Wyckoff, M. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Part+13%3A+Neonatal+resuscitation%3A+2015+American+Heart+Association+guidelines+update+for+cardiopulmonary+resuscitation+and+emergency+cardiovascular+care%5BTitle%5D)+AND+%22Circulation%22%5BJournal%5D)">Part 13: Neonatal resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.</a> Circulation. 132 (18 Suppl 2), S543-S560 (2015).</li>
<li>Marshall, S., Lang, A. M., Perez, M., Saugstad, O. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Delivery+room+handling+of+the+newborn%5BTitle%5D)+AND+%22Journal+of+Perinatal+Medicine%22%5BJournal%5D)">Delivery room handling of the newborn.</a> Journal of Perinatal Medicine. 48 (1), 1-10 (2019).</li>
<li>Lioy, J., Paliga, J. T., Deshmuhk, H. <a target="_blank" href="http://scholar.google.com/scholar?hl=en&safe=off&q=author%3aLioy%2C+J+%22Airway+Emergencies+in+the+Neonate%3A+Preparedness+at+the+Bedside.+Disorders+of+the+Neonatal+Airway%22">Airway Emergencies in the Neonate: Preparedness at the Bedside. Disorders of the Neonatal Airway</a>. , Springer, New York, NY. (2015).</li>
<li>Sawyer, T., Motz, P., Schooley, N., Umoren, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Positive+pressure+ventilation+coaching+during+neonatal+bag-mask+ventilation%3A+A+simulation-based+pilot+study%5BTitle%5D)+AND+%22Journal+of+Neonatal-Perinatal+Medicine%22%5BJournal%5D)">Positive pressure ventilation coaching during neonatal bag-mask ventilation: A simulation-based pilot study.</a> Journal of Neonatal-Perinatal Medicine. 12 (3), 243-248 (2019).</li>
<li>O'Donnell, C. P. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Neonatal+resuscitation+2%3A+an+evaluation+of+manual+ventilation+devices+and+face+masks%5BTitle%5D)+AND+%22Archives+of+Disease+in+Childhood+-+Fetal+and+Neonatal+Edition%22%5BJournal%5D)">Neonatal resuscitation 2: an evaluation of manual ventilation devices and face masks.</a> Archives of Disease in Childhood - Fetal and Neonatal Edition. 90 (5), F392-F396 (2005).</li>
<li>Udaeta, M. E., Weiner, G. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Alternative+ventilation+strategies%3A+laryngeal+masks%5BTitle%5D)+AND+%22Clinics+in+Perinatology%22%5BJournal%5D)">Alternative ventilation strategies: laryngeal masks.</a> Clinics in Perinatology. 33 (1), 99-110 (2006).</li>
<li>Bismilla, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Failure+of+pediatric+and+neonatal+trainees+to+meet+Canadian+Neonatal+Resuscitation+Program+standards+for+neonatal+intubation%5BTitle%5D)+AND+%22Journal+of+Perinatology%22%5BJournal%5D)">Failure of pediatric and neonatal trainees to meet Canadian Neonatal Resuscitation Program standards for neonatal intubation.</a> Journal of Perinatology. 30 (3), 182-187 (2010).</li>
<li>Leone, T. A., Rich, W., Finer, N. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Neonatal+intubation%3A+Success+of+pediatric+trainees%5BTitle%5D)+AND+%22The+Journal+of+Pediatrics%22%5BJournal%5D)">Neonatal intubation: Success of pediatric trainees.</a> The Journal of Pediatrics. 146 (5), 638-641 (2005).</li>
<li>Escobedo, M. B., Shah, B. A., Song, C., Makkar, A., Szyld, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Recent+recommendations+and+emerging+science+in+neonatal+resuscitation%5BTitle%5D)+AND+%22Pediatric+Clinics+of+North+America%22%5BJournal%5D)">Recent recommendations and emerging science in neonatal resuscitation.</a> Pediatric Clinics of North America. 66 (2), 309-320 (2019).</li>
<li>Kattwinkel, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Part+15%3A+Neonatal+Resuscitation%5BTitle%5D)+AND+%22Circulation%22%5BJournal%5D)">Part 15: Neonatal Resuscitation.</a> Circulation. 122 (18_suppl_3), S909-S919 (2010).</li>
<li>Caldwell, P., Srinivasjois, R., Earley, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Use+of+laryngeal+mask+airway+in+near-term+and+term+neonates+during+resuscitation%3A+is+it+effective+and+safe%5BTitle%5D)+AND+%22Journal+of+Paediatrics+and+Child+Health%22%5BJournal%5D)">Use of laryngeal mask airway in near-term and term neonates during resuscitation: is it effective and safe.</a> Journal of Paediatrics and Child Health. 47 (10), 753-756 (2011).</li>
<li>Shah, B. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laryngeal+mask+use+in+the+neonatal+population%3A+A+survey+of+practice+providers+at+a+regional+tertiary+care+center+in+the+United+States%5BTitle%5D)+AND+%22American+Journal+of+Perinatology%22%5BJournal%5D)">Laryngeal mask use in the neonatal population: A survey of practice providers at a regional tertiary care center in the United States.</a> American Journal of Perinatology. , (2021).</li>
<li>White, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laryngeal+mask+ventilation+during+neonatal+resuscitation%3A+A+case+series%5BTitle%5D)+AND+%22Children%22%5BJournal%5D)">Laryngeal mask ventilation during neonatal resuscitation: A case series.</a> Children. 9 (6), 897(2022).</li>
<li>Berry, A. M., Brimacombe, J. R., Verghese, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+laryngeal+mask+airway+in+emergency+medicine%2C+neonatal+resuscitation%2C+and+intensive+care+medicine%5BTitle%5D)+AND+%22International+Anesthesiology+Clinics%22%5BJournal%5D)">The laryngeal mask airway in emergency medicine, neonatal resuscitation, and intensive care medicine.</a> International Anesthesiology Clinics. 36 (2), 91-109 (1998).</li>
<li>Wall, S. N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Neonatal+resuscitation+in+low-resource+settings%3A+what%2C+who%2C+and+how+to+overcome+challenges+to+scale+up%5BTitle%5D)+AND+%22International+Journal+of+Gynaecology+and+Obstetrics%22%5BJournal%5D)">Neonatal resuscitation in low-resource settings: what, who, and how to overcome challenges to scale up.</a> International Journal of Gynaecology and Obstetrics. 107 Suppl 1 (Suppl 1), S47-62-S63-44 (2009).</li>
<li>Hainstock, L. M., Raval, G. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Neonatal+resuscitation%5BTitle%5D)+AND+%22Pediatrics+in+Review%22%5BJournal%5D)">Neonatal resuscitation.</a> Pediatrics in Review. 41 (3), 155-158 (2020).</li>
<li>Niles, D. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Incidence+and+characteristics+of+positive+pressure+ventilation+delivered+to+newborns+in+a+US+tertiary+academic+hospital%5BTitle%5D)+AND+%22Resuscitation%22%5BJournal%5D)">Incidence and characteristics of positive pressure ventilation delivered to newborns in a US tertiary academic hospital.</a> Resuscitation. 115, 102-109 (2017).</li>
<li>Skare, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Ventilation+fraction+during+the+first+30s+of+neonatal+resuscitation%5BTitle%5D)+AND+%22Resuscitation%22%5BJournal%5D)">Ventilation fraction during the first 30s of neonatal resuscitation.</a> Resuscitation. 107, 25-30 (2016).</li>
<li>Bansal, S. C., Caoci, S., Dempsey, E., Trevisanuto, D., Roehr, C. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+laryngeal+mask+airway+and+its+use+in+neonatal+resuscitation%3A+A+critical+review+of+where+we+are+in+2017%2F2018%5BTitle%5D)+AND+%22Neonatology%22%5BJournal%5D)">The laryngeal mask airway and its use in neonatal resuscitation: A critical review of where we are in 2017/2018.</a> Neonatology. 113 (2), 152-161 (2018).</li>
<li>Qureshi, M. J., Kumar, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laryngeal+mask+airway+versus+bag-mask+ventilation+or+endotracheal+intubation+for+neonatal+resuscitation%5BTitle%5D)+AND+%22The+Cochrane+Database+of+Systematic+Reviews%22%5BJournal%5D)">Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation.</a> The Cochrane Database of Systematic Reviews. 3 (3), CD03314(2018).</li>
<li>Belkhatir, K., Scrivens, A., O'Shea, J. E., Roehr, C. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Experience+and+training+in+endotracheal+intubation+and+laryngeal+mask+airway+use+in+neonates%3A+results+of+a+national+survey%5BTitle%5D)+AND+%22Archives+of+Disease+in+Childhood%22%5BJournal%5D)">Experience and training in endotracheal intubation and laryngeal mask airway use in neonates: results of a national survey.</a> Archives of Disease in Childhood. 106 Fetal and Neonatal Edition, (2), 223-224 (2021).</li>
<li>Foglia, E. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Neonatal+intubation+practice+and+outcomes%3A+an+international+registry+study%5BTitle%5D)+AND+%22Pediatrics%22%5BJournal%5D)">Neonatal intubation practice and outcomes: an international registry study.</a> Pediatrics. 143 (1), e20180902(2019).</li>
<li>Konrad, C., Schupfer, G., Wietlisbach, M., Gerber, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Learning+manual+skills+in+anesthesiology%3A+Is+there+a+recommended+number+of+cases+for+anesthetic+procedures%5BTitle%5D)+AND+%22Anesthesia+and+Analgesia%22%5BJournal%5D)">Learning manual skills in anesthesiology: Is there a recommended number of cases for anesthetic procedures.</a> Anesthesia and Analgesia. 86 (3), 635-639 (1998).</li>
<li>Pejovic, N. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Neonatal+resuscitation+using+a+laryngeal+mask+airway%3A+A+randomised+trial+in+Uganda%5BTitle%5D)+AND+%22Archives+of+Disease+in+Childhood%22%5BJournal%5D)">Neonatal resuscitation using a laryngeal mask airway: A randomised trial in Uganda.</a> Archives of Disease in Childhood. 103 (3), 255-260 (2018).</li>
<li>Yamada, N. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Supraglottic+airways+compared+with+face+masks+for+neonatal+resuscitation%3A+A+systematic+review%5BTitle%5D)+AND+%22Pediatrics%22%5BJournal%5D)">Supraglottic airways compared with face masks for neonatal resuscitation: A systematic review.</a> Pediatrics. 150 (3), e2022056568(2022).</li>
</ol>

The authors have no conflicts of interest relevant to this article to disclose.

Training in newborn resuscitation can reduce term intrapartum-related deaths by 30%18. The Oklahoma Children&#39;s Hospital at University of Oklahoma (OU) Health, located on the campus of the University of Oklahoma Health Sciences Center in Oklahoma City, OK, requires all healthcare providers who assist in the management of newborns to maintain up-to-date NRP training. According to the current NRP guidelines, the most vital aspect of neonatal resuscitation is the effective delivery of positive pre...

Birth asphyxia accounts for ~1 million deaths each year and is a primary cause of early neonatal mortality1.&#160;In high-income countries, the incidence of perinatal asphyxia is ~1/1000 live births; it can be up to 10 times higher in low-middle-income countries1. Approximately 15%-20% of asphyxiated infants die in the first month of life and up to one-fourth of survivors sustain permanent neurologic deficits2,3. As reported by the Centers for Disease Control and Prevention, intrauterine hypoxia and birth asphyxia account for 10% of infant mortality4. In the United States, 10% of all newborns need assistance in the delivery room to breathe, with less than 1% needing more advanced resuscitative measures such as cardiac compressions and medications5. Interventions within the first minute of life have important long-term implications for outcomes6.
Effective ventilation using a face mask is often challenging for those who infrequently perform neonatal resuscitation. Resultant hypoxia, bradycardia, and emergent tracheal intubation increase unanticipated neonatal intensive care unit (NICU) admissions. The most common problems associated with a poor face mask technique include mask leakage, air blockage, and insufficient chest excursion7,8,9. NRP includes ventilation corrective steps, but mastery of these skills is difficult if not performed often.
The American Heart Association and American Academy of Pediatrics developed the Neonatal Resuscitation Program (NRP) to teach an evidence-based approach to newborn care. The NRP algorithm calls for tracheal intubation when face mask ventilation is ineffective or prolonged5. However, pediatric trainees have also shown difficulty performing intubation and have few opportunities to practice10,11,12. An SGA is an appropriate alternative airway in newborns weighing &#62;1500 g when face mask ventilation is insufficient and endotracheal intubation is unsuccessful or not feasible13,14,15,16. Although many studies support the feasibility and utility of SGA for initial respiratory management in low-middle-income countries, there is a paucity of data to support the use of SGA to perform initial PPV in high-income countries9,10,11.
We speculate that the mastery of SGA use has the potential to reduce PPV interruptions and therefore improve resuscitation outcomes. Our overarching objective was to evaluate the effectiveness of focused SGA training on newborn resuscitation outcomes, including PPV duration, ventilation failures, and complications.

<table><tbody><tr><td>CO&lt;sub&gt;2&lt;/sub&gt; detector</td><td>Medtronic USA</td><td>42271500</td><td>Nellcor pediatric colorimetric CO&lt;sub&gt;2&lt;/sub&gt; detector (pedicap)</td></tr><tr><td>I-gel supraglottic airway</td><td>Intersurgical</td><td>8201000</td><td>Neonatal size # 1</td></tr><tr><td>Lubricant</td><td>Laerdal Medical AS</td><td>252090</td><td>Airway Lubricant Spray Can (180 mL)</td></tr><tr><td>Neonatal Patient Simulator&amp;nbsp;</td><td>Laerdal Medical AS</td><td>296-00050</td><td>SimNewB Light tetherless</td></tr><tr><td>Positive pressure ventilation device</td><td>Fisher &amp;amp; Paykel Healthcare</td><td>RD900</td><td>Neopuff Infant T-Piece Resuscitator</td></tr></tbody></table>

laryngeal mask airway (lma) placement in a neonatal patient simulator using a non-inflatable supraglottic airway (sga)

The effective delivery of positive pressure ventilation (PPV) can be challenging during neonatal resuscitation. Achieving a patent airway through an appropriate interface during neonatal resuscitation is critical for avoiding airway obstruction and leakage and optimizing access to PPV. Due to the complexity of face mask ventilation, providers have explored corrective steps. However, these methods are difficult to master and thus may present a risk for ventilation delay and/or interruptions at the critical time of resuscitation and the development of complications. In addition, neonatal endotracheal intubation is an invasive procedure that requires significant practice and training. The supraglottic airway (SGA) is a useful laryngeal mask airway (LMA) interface that decreases the time required to achieve a secure airway and reduces the need for endotracheal intubation. Despite the available evidence regarding its effectiveness, insufficient training and awareness limit SGA use in the real world, and frontline providers report low confidence in SGA placement. Here we provide a detailed description of SGA placement, the instruction of which requires only minimal training and leads to a short time to proficiency. Briefly, after the administration of initial ventilatory corrective steps in a neonatal manikin, a provider inserts a non-inflatable SGA into the larynx. This method allows for a single individual to provide effective delivery of PPV in a noninvasive manner without the need for expensive equipment such as video laryngoscopy. Instructors can easily teach this technique with ease and little cost in any clinical and research setting. This is also true for different income settings, including high-, middle-, and low-income countries.

Following successful SGA placement, effective PPV can be confirmed by listening for air entry bilaterally in the lungs and visualizing chest wall movement with ventilation (Figure 1). Occasionally, an incorrect position can result in ineffective lung aeration, resulting in failure to raise heart rate, improvements in oxygen saturation, and a color change to yellow on the CO2 colorimeter.
A recent case series17 at our institution'...

Watch this Scientific Journal Video about Laryngeal Mask Airway LMA Placement in a Neonatal Patient Simulator Using a Non-Inflatable Supraglottic Airway SGA at JoVE.com

Laryngeal Mask Airway LMA Placement in a Neonatal Patient Simulator Using a Non-Inflatable Supraglottic Airway SGA

This protocol is designed to describe a method to place and establish a supraglottic (alternative) airway during neonatal resuscitation. It can be used in situations where frontline providers cannot ventilate or endotracheally intubate neonates requiring resuscitation.

Laryngeal Mask Airway (LMA) Placement in a Neonatal Patient Simulator Using a Non-Inflatable Supraglottic Airway (SGA)

The effective delivery of positive pressure ventilation (PPV) can be challenging during neonatal resuscitation. Achieving a patent airway through an ...

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2.7K Views.  University of Oklahoma (OU) Health Sciences Center. Deze methode kan helpen bij het beantwoorden van belangrijke vragen op het gebied van reanimatie van pasgeborenen, die de overgang van foetaal naar neonataal leven overbrugt. Het belangrijkste voordeel van deze techniek is dat deze kan worden gebruikt in uitdagende situaties waarin eerstelijnszorgverleners pasgeborenen die reanimatie nodig hebben, niet kunnen beademen of endotracheaal kunnen intuberen. De implicaties van deze techniek strekken zich uit tot de therapie van respiratory distress...

Video: Laryngeal Mask Airway LMA Placement in a Neonatal Patient Simulator Using a Non-Inflatable Supraglottic Airway SGA

A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which works especially well with poor mask fit.
Can not intubate, can not ventilate" (CICV) is a potentially life threatening situation. In this video we present a simulation of the technique we used in a case of CICV where oxygenation and ventilation were maintained by inserting an endotracheal tube (ETT) nasally down to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation.
A 13 year old patient was taken to the operating room for incision and drainage of a neck abcess and direct laryngobronchoscopy. After preoxygenation, anesthesia was induced intravenously. Mask ventilation was found to be extremely difficult because of the swelling of the soft tissue. The face mask could not fit properly on the face due to significant facial swelling as well. A direct laryngoscopy was attempted with no visualization of the larynx. Oxygen saturation was difficult to maintain, with saturations falling to 80%. In order to oxygenate and ventilate the patient, an endotracheal tube was then inserted nasally after nasal spray with nasal decongestant and lubricant. The tube was pushed gently and blindly into the hypopharynx. The mouth and nose of the patient were sealed by hand and positive pressure ventilation was possible with 100% O2 with good oxygen saturation during that period of time. Once the patient was stable and well sedated, a rigid bronchoscope was introduced by the otolaryngologist showing extensive subglottic and epiglottic edema, and a mass effect from the abscess, contributing to the airway compromise. The airway was secured with an ETT tube by the otolaryngologist.This video will show a simulation of the technique on a patient undergoing general anesthesia for dental restorations.

We describe a technique to maintain oxygenation and ventilation using an endotracheal tube inserted nasally to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation.

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which ...

A Piglet Model of Neonatal Hypoxic-Ischemic Encephalopathy

Birth asphyxia, which causes hypoxic-ischemic encephalopathy (HIE), accounts for 0.66 million deaths worldwide each year, about a quarter of the world&#8217;s 2.9 million neonatal deaths. Animal models of HIE have contributed to the understanding of the pathophysiology in HIE, and have highlighted the dynamic process that occur in brain injury due to perinatal asphyxia. Thus, animal studies have suggested a time-window for post-insult treatment strategies. Hypothermia has been tested as a treatment for HIE in pdiglet models and subsequently proven effective in clinical trials. Variations of the model have been applied in the study of adjunctive neuroprotective methods and piglet studies of xenon and melatonin have led to clinical phase I and II trials1,2. The piglet HIE model is further used for neonatal resuscitation- and hemodynamic studies as well as in investigations of cerebral hypoxia on a cellular level. However, it is a technically challenging model and variations in the protocol may result in either too mild or too severe brain injury. In this article, we demonstrate the technical procedures necessary for establishing a stable piglet model of neonatal HIE. First, the newborn piglet (&#60; 24 hr old, median weight 1500 g) is anesthetized, intubated, and monitored in a setup comparable to that found in a neonatal intensive care unit. Global hypoxia-ischemia is induced by lowering the inspiratory oxygen fraction to achieve global hypoxia, ischemia through hypotension and a flat trace amplitude integrated EEG (aEEG) indicative of cerebral hypoxia. Survival is promoted by adjusting oxygenation according to the aEEG response and blood pressure. Brain injury is quantified by histopathology and magnetic resonance imaging after 72 hr.

Hypoxic-ischemic encephalopathy following perinatal asphyxia can be studied using animal models. We demonstrate the procedures necessary for establishing a piglet model of neonatal hypoxic-ischemic encephalopathy.

Birth asphyxia, which causes hypoxic-ischemic encephalopathy (HIE), accounts for 0.66 million deaths worldwide each year, about a quarter of the ...

Anatomically Realistic Neonatal Heart Model for Use in Neonatal Patient Simulators

Neonatal patient simulators (NPS) are artificial patient surrogates used in the context of medical simulation training. Neonatologists and nursing staff practice clinical interventions such as chest compressions to ensure patient survival in the case of bradycardia or cardiac arrest. The simulators used currently are of low physical fidelity and therefore cannot provide qualitative insight into the procedure of chest compressions. The embedding of an anatomically realistic heart model in future simulators enables the detection of cardiac output generated during chest compressions; this can provide clinicians with an output parameter, which can deepen the understanding of the effect of the compressions in relation to the amount of blood flow generated. Before this monitoring can be achieved, an anatomically realistic heart model must be created containing: two atria, two ventricles, four heart valves, pulmonary veins and arteries, and systemic veins and arteries. This protocol describes the procedure for creating such a functional artificial neonatal heart model by utilizing a combination of magnetic resonance imaging (MRI), 3D printing, and casting in the form of cold injection molding. Using this method with flexible 3D printed inner molds in the injection molding process, an anatomically realistic heart model can be obtained.

This protocol describes a procedure for creating functional artificial neonatal heart models by utilizing a combination of magnetic resonance imaging, 3D printing, and injection molding. The purpose of these models is for integration into the next generation of neonatal patient simulators and as a tool for physiological and anatomical studies.

Neonatal patient simulators (NPS) are artificial patient surrogates used in the context of medical simulation training. Neonatologists and nursing staff ...

Bioengineering

Manufacture of a Multi-Purpose Low-Cost Animal Bench-Model for Teaching Tracheostomy

Tracheostomy is one of the most frequent procedures, performed through various techniques in the intensive care unit and emergency situations. Despite this, there is a lack of training on this procedure that affects its outcome, which is also dependent on operator's dexterity. Here, we take the specific training and simulation into consideration. This article aims to describe every step of the manufacture of a new multi-purpose low-cost animal bench-model, with the support of video and images, and to obtain an opinion about the quality of this model by administering a questionnaire to professionals with experience in the procedures. 
Ten experts in the technique were enrolled. The model scored an average of 3.45/5 for its anatomical realism; 4.75/5 for its usefulness as a training tool for simulation courses and assessments. The time necessary to build the model was 15 minutes, and the cost amounted to 10&#8364;. The animal bench-model was considered a very useful simulator for tracheostomy training and assessments. Therefore, it could be used as a tool for medical courses and residencies.

This article illustrates every step of the manufacture of a new multi-purpose low-cost animal bench-model for subglottic airway access management. All the procedures are shown in the video. The model's realism and its suitability for training the given clinical maneuvers were assessed by independent senior otolaryngologists and anesthesiologists.

Tracheostomy is one of the most frequent procedures, performed through various techniques in the intensive care unit and emergency situations. Despite ...

The Rigid Tube as an Alternative in Controlling the Problematic Airway

The unexpected problematic airway represents a large proportion of anesthesia-related morbidity and mortality. The retromolar or paraglossal approach is an alternative to the majority of the rigid instruments used for tracheal intubation, which follow the midline to access the glottis. This single-center, prospective case-series study offers an option to conventional laryngoscopy in case of a poor glottic view, introducing an instrument (the rigid tube for laryngoscopy) that uses the retromolar approach to accomplish tracheal intubation. If after anesthesia induction, the modified Cormack-Lehane glottis view grade &#62;2b, the intubation is carried further with the rigid tube. The tube follows the direction of the thyroid cartilage while advancing from the labial commissure, displacing the tongue to the contralateral side. Adjusting the position of the larynx with the nondominant hand by gently pushing the thyroid cartilage and following an imaginary line towards it while advancing it improves the time needed for proper glottis visualization. Once the epiglottis is in sight, the practitioner progresses slowly, lifting the epiglottis and aiming the tip of the tube more anteriorly. When the glottis appears in the visual field, the intubating tube introducer is placed in the trachea, and a lubricated cuffed intubating tube is advanced over the introducer after the rigid tube is extracted. This tool was tested on 30 patients with an unsatisfactory glottic view when using the Macintosh laryngoscope and obtained excellent results with respect to intubation time and complications. The reduced visual field is the main limitation of this method, which requires a training period for reasonable expertise. This simple, robust, and cheap instrument could be a rescue option in case of a difficult airway.

Presented here is a protocol of tracheal intubation over an intubating tube introducer using a rigid tube for laryngoscopy with an attached light source. The main characteristics of this maneuver are the retromolar approach and the use of the thyroid cartilage as a landmark while advancing the rigid tube.

The unexpected problematic airway represents a large proportion of anesthesia-related morbidity and mortality. The retromolar or paraglossal approach is ...

Blind Endotracheal Intubation in Neonatal Rabbits

The newborn rabbit is a useful animal model for various pathologies and procedures. Airway management of the rabbit is complex due to its anatomical characteristics, which is further complicated in the case of the newborn. Of the different methods of advanced airway management, endotracheal intubation is less aggressive than tracheostomy, and is more feasible than supraglottic management given the lack of supraglottic devices of such a small size. As direct glottis visualization is very difficult in animals this size, this blind intubation model is presented as an effective alternative, especially for experiments requiring prolonged anesthesia. Using this method, we performed blind intubations with a 90% success rate.

We describe a technique of endotracheal intubation in newborn rabbits after esophageal catheterization with a gastric tube.

The newborn rabbit is a useful animal model for various pathologies and procedures. Airway management of the rabbit is complex due to its anatomical ...

Endoscopic Approach for Studying Laryngeal Dysfunction in Rodents

Minimally Invasive Murine Laryngoscopy for Close&#45;Up Imaging of Laryngeal Motion During Breathing and Swallowing

The larynx is an essential organ in mammals with three primary functions - breathing, swallowing, and vocalizing. A wide range of disorders are known to impair laryngeal function, which results in difficulty&#160;breathing (dyspnea), swallowing impairment (dysphagia), and/or voice impairment (dysphonia). Dysphagia, in particular, can lead to aspiration pneumonia and associated morbidity, recurrent hospitalization, and early mortality. Despite these serious consequences, existing treatments for laryngeal dysfunction are largely aimed at surgical and behavioral interventions that unfortunately do not typically restore normal laryngeal function, thus highlighting the urgent need for innovative solutions.
To bridge this gap, we have been developing an experimental endoscopic approach to investigate laryngeal dysfunction in murine (i.e., mouse and rat) models. However, endoscopy in rodents is quite challenging due to their small size relative to current endoscope technology, anatomical differences in the upper airway, and the necessity for anesthesia to optimally access the larynx. Here, we describe a novel transoral laryngoscopy approach that permits close-up, unobstructed video imaging of laryngeal motion in mice and rats. Critical steps in the protocol include precise anesthesia management (to prevent overdosing that abolishes swallowing and/or risks respiratory distress-related mortality) and micromanipulator control of the endoscope (for stable video recording of laryngeal motion by a single researcher for subsequent quantification).
Importantly, the protocol can be performed over time in the same animals to study the impact of various pathological conditions specifically on laryngeal function. A novel advantage of this protocol is the ability to visualize airway protection during swallowing, which is not possible in humans due to epiglottic inversion over the laryngeal inlet that obstructs the glottis from view. Rodents therefore provide a unique opportunity to specifically investigate the mechanisms of normal versus pathological laryngeal airway protection for the ultimate purpose of discovering treatments to effectively restore normal laryngeal function.

This protocol describes a serial transoral laryngoscopy approach for mice and rats that permits close-up, unobstructed video imaging of the larynx during breathing and swallowing using an optimized anesthetic regimen and finely tuned endoscopic manipulation techniques.

The larynx is an essential organ in mammals with three primary functions - breathing, swallowing, and vocalizing. A wide range of disorders are known to ...

Neuroscience

Endotracheal Intubation Using a Flexible Intubation Endoscope as a Standardized Model for Safe Airway Management in Swine

Endotracheal intubation is often a basic requirement for translational research in porcine models for various interventions that require a secured airway or high ventilation pressures. Endotracheal intubation is a challenging skill,&#160;requiring a minimum number of successful endotracheal intubations to achieve a high success rate under optimal conditions, which is often unachievable for non-anaesthesiology researchers. Due to the specific porcine airway anatomy, a difficult airway can usually be assumed. The impossibility of establishing a secure airway can result in injury, adverse events, or death of the laboratory animal. Using a prospective, randomized, controlled evaluation approach, it has been shown that fiberoptic-assisted endotracheal intubation takes longer but has a higher first-pass success rate than conventional intubation without causing clinically relevant drops in oxygen saturation. This model presents a standardized regimen for endoscopically guided endotracheal intubation, providing a secured airway, especially for researchers who are inexperienced in the technique of endotracheal intubation via direct laryngoscopy. This procedure is expected to minimize animal suffering and unnecessary animal losses.

The use of pigs in research has increased in recent years. Nevertheless, pigs are characterized by difficult airway anatomy. By demonstrating how to perform endoscopically guided endotracheal intubation, the present protocol aims to further increase laboratory animals' safety to avoid animal suffering and unnecessary death.

Endotracheal intubation is often a basic requirement for translational research in porcine models for various interventions that require a secured airway ...

Image Acquisition using Portable Sonography for Emergency Airway Management

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of patients, but also to address the potential benefits of employing ultrasound in airway management. The benefits of point of care ultrasound (POCUS) include its portability, the speed at which it can be utilized, and its lack of invasiveness or exposure of the patient to radiation of other imaging modalities.
Two primary indications for airway POCUS include confirmation of endotracheal intubation and identification of the cricothyroid membrane in the event a surgical airway is required. In this article, the technique of using ultrasound to confirm endotracheal intubation and the relevant anatomy is described, along with the associated ultrasonographic images. In addition, identification of the anatomy of the cricothyroid membrane and the ultrasonographic acquisition of appropriate images to perform this procedure are reviewed.
Future advances include utilizing airway POCUS to identify patient characteristics that might indicate difficult airway management. Traditional bedside clinical exams have, at best, fair predictive values. The addition of ultrasonographic airway assessment has the potential to improve this predictive accuracy. This article describes the use of POCUS for airway management, and initial evidence suggests that this has improved the diagnostic accuracy of predicting a difficult airway. Given that one of the limitations of airway POCUS is that it requires a skilled sonographer, and image analysis can be operator dependent, this paper will provide recommendations to standardize the technical aspects of airway ultrasonography and promote further research utilizing sonography in airway management. The goal of this protocol is to educate researchers and medical health professionals and to advance the research in the field of airway POCUS.

Point of care ultrasound (POCUS) is increasingly being utilized in airway management. Presented here are some clinical utilities of POCUS, including differentiating endotracheal and esophageal intubation, identification of the cricothyroid membrane in the event a surgical airway is required, and measuring anterior neck soft tissue to predict difficult airway management.

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of ...

A Modified Sonographic Algorithm for Image Acquisition in Life-Threatening Emergencies in the Critically Ill Newborn

The use of routine point-of-care ultrasound (POCUS) is increasing in neonatal intensive care units (NICUs), with several centers advocating for 24 h equipment availability. In 2018, the sonographic algorithm for life-threatening emergencies (SAFE) protocol was published, which allows the assessment of neonates with sudden decompensation to identify abnormal contractility, tamponade, pneumothorax, and pleural effusion. In the study unit (with a consulting neonatal hemodynamics and POCUS service), the algorithm was adapted by including consolidated core steps to support at-risk newborns, aiding clinicians in managing cardiac arrest, and adding views to verify correct intubation. This paper presents a protocol that can be applied in the NICU and the delivery room (DR) in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation. 
This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; the image acquisition protocol is carefully detailed. This method was designed to be learned as a general competence to obtain the timely diagnosis of life-threatening scenarios; the method aims to save time but does not represent a substitute for comprehensive and standardized hemodynamic and radiological analyses by a multidisciplinary team, which might not universally be on call but needs to be involved in the process. From January 2019 to July 2022, in our center, 1,045 hemodynamic consultation/POCUS consults were performed with 25 patients requiring the modified SAFE protocol (2.3%), and a total of 19 procedures were performed. In five cases, trained fellows on call resolved life-threatening situations. Clinical examples are provided that show the importance of including this technique in the care of critical newborns.

Here, we present a protocol that can be applied in the neonatal intensive care unit and the delivery room in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation. This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; an image acquisition protocol is carefully detailed.

The use of routine point-of-care ultrasound (POCUS) is increasing in neonatal intensive care units (NICUs), with several centers advocating for 24 h ...

Laryngeal Mask Airway (LMA) Placement in a Neonatal Patient Simulator Using a Non-Inflatable Supraglottic Airway (SGA)

Samenvatting

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