Laryngeal mask use during neonatal resuscitation at birth: A United States-based survey of neonatal resuscitation program providers and instructors

Aim Neonatal resuscitation guidelines promote the laryngeal mask (LM) interface for positive pressure ventilation (PPV), but little is known about how the LM is used among Neonatal Resuscitation Program (NRP) Providers and Instructors. The study aim was to characterize the training, experience, confidence, and perspectives of NRP Providers and Instructors regarding LM use during neonatal resuscitation at birth. Methods A voluntary anonymous survey was emailed to all NRP Providers and Instructors. Survey items addressed training, experience, confidence, and barriers for LM use during resuscitation. Associations between respondent characteristics and outcomes of both LM experience and confidence were assessed using logistic regression. Results Between 11/7/22–12/12/22, there were 5,809 survey respondents: 68% were NRP Providers, 55% were nurses, and 87% worked in a hospital setting. Of these, 12% had ever placed a LM during newborn resuscitation, and 25% felt very or completely confident using a LM. In logistic regression, clinical or simulated hands-on training, NRP Instructor role, professional role, and practice setting were all associated with both LM experience and confidence. The three most frequently identified barriers to LM use were insufficient experience (46%), preference for other interfaces (25%), and failure to consider the LM during resuscitation (21%). One-third (33%) reported that LMs are not available where they resuscitate newborns. Conclusion Few NRP providers and instructors use the LM during neonatal resuscitation. Strategies to increase LM use include hands-on clinical training, outreach promoting the advantages of the LM compared to other interfaces, and improving availability of the LM in delivery settings.


Introduction
Up to 10% of all newborns require resuscitation to breathe immediately after birth. 1 Positive pressure ventilation (PPV) is the most important intervention during neonatal resuscitation. 1,2PPV is typically performed with a facemask, but mask leak and airway obstruction are common obstacles to effective ventilation.American Heart Association/American Academy of Pediatrics Neonatal Resuscitation Guidelines recommend "ventilation corrective steps" to troubleshoot impediments. 3However, these steps are variably performed, can worsen ventilation quality, and may delay advanced airway placement, prolonging bradycardia and hypoxia. 4he endotracheal tube is the most common alternative airway used during neonatal resuscitation.However, endotracheal intubation requires advanced technical skills and carries significant procehttps://doi.org/10.1016/j.resplu.Available online at www.sciencedirect.com

Resuscitation Plus
journal homepage: www.elsevier.com/locate/resuscitation-plusdural risks. 5A laryngeal mask (LM), or supraglottic airway, is an alternative airway that is widely available and promoted in neonatal resuscitation guidelines. 3Despite this, little is known about LM use during neonatal resuscitation in high-resource settings.A singlecenter study in the United States (US) identified barriers to LM use including limited experience, insufficient training, endotracheal tube preference, and lack of awareness. 6ittle is known about Neonatal Resuscitation Program (NRP) Providers' use and perceptions for the LM during neonatal resuscitation.We conducted this survey to characterize current experience, use, perceived barriers, and implementation readiness for the LM across a contemporary cohort of NRP Providers and Instructors.

Methods
An invitation to participate in the survey was disseminated from the American Academy of Pediatrics to email addresses of 425,762 NRP Providers and Instructors on the NRP listserv.Most listserv members are US-based.Interested respondents accessed an embedded link to an anonymous electronic survey between 11/7/22 and 12/12/22.Study data were collected and managed using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at University of Oklahoma Health Sciences Center. 7,8wo reminder emails were sent with two weeks between emails, and the survey was closed one week after the final email reminder.The American Academy of Pediatrics and the University of Oklahoma Health Sciences Center Institutional Review Boards reviewed this study and deemed it exempt from oversight.Written informed consent was waived; the invitation specified that participation was voluntary and that participation in the survey implied consent.
The survey (supplemental material) included questions adapted from a previous single center study. 6Consistent with the NRP terminology, we used the term "laryngeal mask." 9 Survey items addressed demographic characteristics, training, experience, and confidence using a LM during resuscitation.The survey prompted respondents to identify up to three barriers to LM use from a prespecified list.Additional questions pertained to LM availability and respondents' perceptions around appropriate timing of the LM use during neonatal resuscitation.Three items assessed LM implementation acceptability, appropriateness, and feasibility on a 5-point Likert scale, using prompts adapted from a validated implementation outcome assessment tool. 10Likert scale responses of "agree" and "completely agree" were consolidated as "agree" for reporting purposes.
The primary outcomes of interest were previous LM use during neonatal resuscitation (yes/no) and confidence using the LM during neonatal resuscitation, measured on a Likert scale from "not at all confident" to "completely confident."For analysis and reporting purposes, responses of "very confident" and "completely confident" were consolidated as "confident," with all other responses being combined as "not confident."Responses for each outcome were summarized based on respondent subgroups related to role, practice setting, and LM training.Generalized linear models with a binomial outcome and a logistic linking function were run in R, version 4.2.3, to analyze the association between respondent characteristics and the two primary outcomes.The logistic model for each outcome included 7 predictors: professional role; current NRP role (Instructor or Provider); primary work setting; number of times participating in newborn resuscitation in the past six months; and binary indicators of having completed didactic, simulated, and clinical training with a LM.A p-value of 0.05 was considered statistically significant.

Results
Responses were received from 5,809 (1.4%) of the listserv members (Table 1).Only 12% of respondents had ever placed a LM during newborn resuscitation, and 25% felt very or completely confident using a LM.
Responses for each of these outcomes based on respondent subgroups are shown in Table 2. Clinical or simulated hands-on training, NRP Instructor role, newborn resuscitation experience, and practice setting were all associated with both LM use and confidence.There were significant differences in both outcomes (previous LM use and confidence) based on professional role (Table 3).
Responses regarding barriers to LM use are presented in Fig. 1.Among respondents, 67% indicated a LM is available in the setting where they resuscitate newborns.When asked to identify the earliest point in the NRP algorithm when LM use is appropriate, 46% of respondents endorsed LM use when facemask PPV is ineffective, and 48% felt the LM to be appropriate when intubation is unsuccessful.Only 3% considered LM use appropriate when PPV is first performed, and 2% indicated LM use is never appropriate for neonatal resuscitation.
Regarding LM implementation questions, 66% of respondents agreed with the statement "I welcome implementation of the laryngeal mask as an alternative airway in my practice setting" (acceptability).Among respondents, 60% agreed that "Implementation of the laryngeal mask as an alternative airway seems like a good match for my practice setting" (appropriateness), and 73% agreed with the statement "Implementation of the laryngeal mask as an alternative airway is possible at my practice setting" (feasibility).

Discussion
We conducted the first US-based national survey of NRP Providers and Instructors regarding LM use during neonatal resuscitation.Although the NRP has endorsed the LM since 2005, 11 just 12% of respondents had ever used a LM during resuscitation, and only 25% felt very or completely confident using the LM.While barriers to LM use were identified, most respondents considered implementation of the LM in their practice setting to be acceptable, appropriate, and feasible.
3][14] We found that 67% of respondents have a LM available where they perform newborn resuscitation.Similarly, Goel et al. recently reported that a LM is available in 67% of NICUs and neonatal transport services in Australia and New Zealand. 15Ensuring a LM is available in every setting where neonatal resuscitation occurs is a straightforward intervention to support LM implementation.
The most common barriers to LM use endorsed by respondents were insufficient experience, preference for other interfaces, and failure to consider the LM during resuscitation.Our results suggest that hands-on training is likely to increase both use and confidence around the LM for resuscitation.Regarding the latter two barriers identified (preference and consideration), we speculate that many neonatal clinicians prioritize intubation when facemask ventilation fails.However, endotracheal intubation requires advanced technical skills and carries significant procedural risks: almost 50% of intubation procedures require at least 2 attempts, 20% result in adverse events, and 4% are complicated by life-threatening severe adverse events. 5In contrast, LM insertion can be learned by inexperienced airway providers in a single training session. 16,17Prioritizing LM over intubation during neonatal resuscitation may improve patient safety by establishing effective ventilation quickly, enabling initial resuscitation providers to establish an alternative airway that does not require advanced airway skills, and decreasing the risk of intubation procedural complications.
Most available evidence has focused on LM as the primary interface when PPV is first performed.A recent meta-analysis demonstrated the LM is superior to facemask as the primary PPV interface to avoid ventilation failure for newborns born at 34 weeks' gestation. 18Importantly, most trials in that metaanalysis were conducted in low-resource settings.We sought to understand the earliest point of the NRP algorithm when respondents considered LM use to be appropriate in the US.Very few survey respondents considered the LM appropriate as the primary interface.Rather, respondents were evenly divided as to considering LM use appropriate when facemask PPV is ineffective ("can't ventilate") or only when intubation is unsuccessful ("can't ventilate and can't intubate").
Our study identified many addressable barriers and may inform implementation strategies for LM use during neonatal resuscitation.At the local level, ensuring a LM is available in every setting where newborn resuscitation is performed is a prerequisite for widespread use.From an educational perspective, hands-on clinical training is likely to improve resuscitation providers' confidence and use of the LM.Finally, respondents' perceptions varied regarding when it is 1 Group frequencies may not sum to the total N because of missing values.Percentages may not sum to 100 because of rounding. 2Number of valid observations for this variable. 3Training types are not mutually exclusive, so percentages will not sum to 100.appropriate to insert the LM during neonatal resuscitation, suggesting there is opportunity to clarify neonatal resuscitation guidelines on this point.We acknowledge study limitations.Given the low response rate, responses may not reflect the experience and perceptions of all NRP Providers and Instructors.Nonetheless, the high absolute number (>5,000) of respondents provide confidence in the precision of responses among participants.In addition, the respondents' professional roles and practice reflect the breadth of providers who are trained in NRP and settings where neonatal resuscitation is performed.Finally, our study is unique in that we also assessed barriers to LM use and implementation readiness.

Conclusion
Few NRP Providers and Instructors use the LM during neonatal resuscitation.Implementation strategies should address LM 2023.100515 Received 25 August 2023; Received in revised form 13 November 2023; Accepted 15 November 2023 2666-5204/Ó 2023 The Authors.Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/ by/4.0/).

Fig. 1 -
Fig. 1 -Barriers to laryngeal mask use identified by NRP Providers and Instructors.Respondents were asked to identify up to 3 barriers to LM use.Abbreviations: LM: laryngeal mask.

Table 2 -
Experience and confidence placing a laryngeal mask during neonatal resuscitation, based on respondent subgroups.

Table 3 -
Multivariable analysis of factors associated with experience and confidence placing a laryngeal mask during neonatal resuscitation.