Laryngeal mask airway versus face mask ventilation or intubation for neonatal resuscitation in low-and-middle-income countries: a systematic review and meta-analysis

Objective To assess whether laryngeal mask airway (LMA) as compared with face mask (FM) or endotracheal intubation (ETT) is more effective in delivering positive pressure ventilation (PPV) during neonatal resuscitation in low-and-middle income countries (LMICs). Study design We followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and searched Medline (PubMed interphase), Cumulative Index of Nursing and Allied Health Literature, Embase and Cochrane Registry between January 1990 and April 2022 for the studies that examined the effect of LMA in delivering PPV compared with the FM or ETT in infants during neonatal resuscitation. We included the studies conducted in LMIC only. We assessed the quality of all the included studies using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) recommendations. Results Our search resulted in eight randomised studies Six studies compared LMA with FM and three studies compared LMA with ETT. When used as the primary device for providing PPV, the LMA as compared with FM resulted in a significant lower failure rate (relative risk (RR) 0.23, 95% CI 0.13 to 0.43) with moderate certainty of evidence (CoE) and lesser need for intubation (RR 0.21, 95% CI 0.07 to 0.58) with low CoE. There was no difference in the incidence of encephalopathy, neonatal admission, need for advanced resuscitations or death. No differences were observed between LMA and ETT. Studies comparing LMA to ETT were limited for any conceivable conclusion. Conclusion LMA is more effective than FM in delivering PPV with less failure rates and reduced need for intubation during neonatal resuscitation in term infants and in LMIC without any difference in the incidence of encephalopathy or death. Studies comparing LMA to ETT are scarce with important methodological limitations. PROSPERO registration number CRD42021283478.