Use of the intubating laryngeal mask airway in the emergency department: A ten-year retrospective review

BackgroundExtraglottic devices, such as the intubating laryngeal mask airway (ILMA), facilitate ventilation and oxygenation and are useful for emergency airway management, especially as rescue devices. In the operating room setting the ILMA has been highly successful. However, its performance in the ED has not been described. We sought to describe the indications for and success of the ILMA when used in the ED.MethodsWe performed retrospective, observational study of patients who had an LMA® Fastrach™ (hereafter termed ILMA) placed in a single ED between 2007 and 2017. Patients were identified by keyword search of ED notes in the electronic medical record. Trained abstractors reviewed charts and videos to determine patient characteristics, indication for ILMA placement, success of oxygenation and ventilation, intubation methods and success, and complications related to the device.ResultsDuring the study period 218 patients had an ILMA placed in the ED. The ILMA was used as a primary device in 118 patients (54%), and as a rescue device in 100 patients (46%). The median number of ILMA uses per faculty physician during the study period was 3. The ILMA oxygenated and ventilated successfully in 212 instances (98%), including 96 times (96%) when used as a rescue airway. Failure of oxygenation was due to tracheal injury (2), abnormal laryngeal inlet anatomy (2), or poor operator technique (1). Intubation through the ILMA was successful in 159 of 192 patients (83%), including a success rate of 81% (112 of 139 patients) with blind intubation.ConclusionThe ILMA was highly successful in oxygenation, with reasonable intubation success, even when used infrequently by emergency physicians. The ILMA should be considered a valuable primary and rescue intubation device in the ED.     

A comparison of the I-gel supraglottic airway as a conduit for tracheal intubation with the intubating laryngeal mask airway: A manikin study

Background

Insertion of a supraglottic airway and tracheal intubation through it may be indicated in resuscitation scenarios where conventional laryngoscopy fails. Various supraglottic devices have been used as conduits for tracheal intubation, including the intubating laryngeal mask airway (ILMA), the Ctrach™ laryngeal mask and the I-gel supraglottic airway.

Methods

A prospective study with 25 participants evaluated the success rate of blind intubation (using a gum-elastic bougie, an Aintree intubating catheter (AIC) and designated tracheal tube) and fibrescope-guided tracheal intubation (through the intubating laryngeal mask airway and the I-gel supraglottic airway) on three different airway manikins.

Results

Twenty-five anaesthetists performed three intubations with each method on each of three manikins. The success rate of the fibrescope-guided technique was significantly higher than blind attempts (P < 0.0001) with both devices. For fibreoptic techniques, there was no difference found between the ILMA and I-gel (P > 0.05). All blind techniques were significantly more successful in the ILMA group compared to the I-gel (P < 0.0001 for bougie, Aintree catheter and tracheal tube, respectively).

Conclusions

The results of this study show that, in manikins, fibreoptic intubation through both ILMA and I-gel is a highly successful technique. Blind intubation through the I-gel showed a low success rate and should not be attempted.     

插管型喉罩用于困难气道的临床研究

目的:观察插管型喉罩(intubating laryngeal mask airway,ILMA)在困难气道中应用的可行性。方法:25例Cormack与lehaneⅢ-Ⅳ级预测为困难气道的择期手术患者(Difficut组,简称D组),另匹配25例Cormack与lehaneⅠ-Ⅱ级的择期手术患者(Control组,简称C组),在静脉诱导后行ILMA插管。观察喉罩置入时间和次数、气管插管时间和次数、插管并发症以及成功率。结果:D组24例(96％)成功经ILMA插入气管导管,其中1次插管成功16例,成功率64％;2次插管成功6例;1例操作失败。C组25例(100％)全部经ILMA成功插入气管导管,其中1次插管成功23例,成功率92％。2次插管成功1例。D组和C组喉罩置入加插管总时间分别为(90．24±8．50)s和(81．26±7．20)s,插管时间分别为(41．73±7．86)s和(40．80±6．93)s。两组在气管导管插入时间、总的ILMA置入时间,成功率、术后并发症等方面无显著差异。结论:插管型喉罩是处理困难气道的有效应用工具之一。     

Intubating laryngeal mask airway placement by non-physician healthcare providers in management out-of-hospital cardiac arrests: A case series

Aim of the study

The role of supralaryngeal devices in airway management in out-of-hospital cardiac arrests (OHCA) remains controversial. The aim of this prospective observational trial was to evaluate the feasibility and effectiveness of intubating laryngeal mask airway (ILMA) when used by trained prehospital emergency nurses in the setting of OHCA.

Methods

After approval from the Research Ethics Board, prehospital emergency nurses trained in placement of ILMA (Fastrach™, LMA Vitaid, Toronto, Ontario, Canada) followed a formal protocol for airway control during OHCA. The primary outcome was the success rate of ILMA placement, while secondary outcomes were success rate of tracheal intubation through the ILMA, and the incidence of regurgitation of gastric contents.

Results

During the study period, 302 ILMA placements were attempted by emergency nurses during OHCA resuscitation. After ILMA placement, but before attempt for intubation, ventilation was possible in 290 patients (96%). Obstruction or major leaks were observed in 12 patients (4%). Tracheal tube insertion through the ILMA was attempted in 265 patients, and was performed in 254 (95.8%). This allowed for proper lung ventilation through the tracheal tube in 242 cases whereas 12 tubes were esophageal or proved obstructed. Regurgitation of gastric contents occurred in 43 (14.2%) patients; in 23 cases before arrival of the first aid team, in 18 cases before ILMA placement, and in 2 cases after the ILMA placement.

Conclusion

The use of ILMA for airway management by trained emergency nurses during OHCA resuscitation is feasible and allows for effective airway management. The success rate of tracheal tube placement through the ILMA was high. In addition, the incidence of regurgitation was lower when using the ILMA than that previous historical reports with face-mask ventilation.     

Successful Tracheal Intubation through an Intubating Laryngeal Airway in Pediatric Patients with Airway Hemorrhage

Background

This case report describes the use of the air-Q intubating laryngeal airway (air-Q ILA; Cookgas LLC, St. Louis, MO) for airway rescue and a conduit for blind tracheal intubation in two pediatric patients with failed rapid sequence intubation and difficult airways secondary to airway bleeding in the emergency department (ED).

Objectives

To describe the use of a new supraglottic rescue device in the management of the pediatric patient’s difficult airway in the emergency setting.

Case Report

Case 1 was a 5-year-old boy who presented to the ED for bleeding one day after his tonsillectomy. After a rapid sequence intubation, direct laryngoscopy was difficult, with copious bleeding in the oropharynx and inability to visualize the glottis. After two failed direct laryngoscopic attempts to intubate, a size-2 air-Q ILA was inserted. A cuffed 5.0-mm inner diameter (ID) endotracheal tube (ETT) was blindly inserted through the lumen of the air-Q ILA into the trachea successfully. Case 2 was a 13-year-old boy who presented to the ED with a large nasopharyngeal laceration from a motor vehicle accident. After a rapid sequence intubation, direct laryngoscopy showed copious blood with no glottic visualization. A size 3 Laryngeal Mask Airway Classic™ (cLMA; LMA North America Inc., San Diego, CA) was inserted with a large airway leak, and blind ETT insertion via the cLMA was unsuccessful. Subsequently, a size-2.5 air-Q ILA was inserted and adequate ventilation was restored. A cuffed 6.0-mm ID ETT was blindly inserted through the air-Q ILA into the trachea successfully.

Conclusion

Two cases of failed laryngoscopy in pediatric patients with blood in the airway are described. In each case, insertion of an air-Q ILA was followed by successful blind tracheal intubation via the lumen of the air-Q ILA.     

Laryngoscopic versus intubating LMA guided tracheal intubation by novice users--a manikin study

AIM OF THE STUDY: Airway control is a potentially lifesaving procedure but tracheal intubation by direct laryngoscopy is difficult. This pilot study was conducted to determine whether tracheal intubation was more rapid and the success rate higher using an intubating laryngeal mask airway. MATERIAL AND METHODS: The success rates of 119 medical students without prior airway management experience in ventilating and then intubating the trachea of a Laerdal Airway Management Trainer with two different methods were compared. The methods were bag-mask ventilation (BM-V) followed by laryngoscopic intubation (LG-TI), and intubating laryngeal mask ventilation (ILMA-V) followed by ILMA-guided tracheal intubation (ILMA-TI). After an introductory lecture and demonstration, each student was allowed three attempts to intubate using each method in random order. RESULTS: All participants were successful with BM-V and ILMA-V on the first attempt. Laryngoscopic tracheal intubation was achieved by 60 (50.4%), 31 (26.1%) and 12 (10.1%) participants on the first, second and third attempt, respectively, while 16 (13.4%) failed in all three attempts. In the ILMA-TI group, 107 (90.0%), 10 (8.4%) and 2 (1.6%) succeeded on the first, second and third attempt, respectively. None failed. The intergroup difference is highly significant (p<0.001). Male participants were more successful with LG-TI than female (p<0.01), but not with ILMA-TI. CONCLUSION: Laryngoscopic orotracheal intubation is difficult for the untrained, but all participants were successful with ILMA-TI. These data suggest that alternative devices such as the ILMA should be included in the medical school curriculum for airway management.     

喷射通气辅助下经喉罩行困难气道气管插管临床研究

目的探讨在喷射通气辅助下经喉罩行困难气道气管插管的方法和可行性。方法选择麻醉前被评估为困难气道、麻醉诱导中发生气管插管困难的择期手术患者68例,随机分为2组:A组(n=34),喷射通气辅助下经LMA气管插管;B组(n=34),经ILMA盲探气管插管。观察两组患者气管导管置入情况及MAP、HR、SPO2、EtCO2、PaO2、PaCO2变化情况。结果两组患者置入LMA或ILMA情况相似,无统计学差异,但和B组相比,A组首次插管成功率明显高于B组,差异有统计学意义(P0.01);麻醉诱导前后各组MAP、HR明显下降而PaO2明显升高,差异显著(P0.05);气管插管操作完成后,B组患者MAP、HR、EtCO2、PaCO2显著升高(P0.05),PaO2显著降低(P0.05);插入导管后,A组MAP、HR、EtCO2、PaCO2明显低于B组(P0.05),PaO2明显高于B组(P0.05)。结论在存在自主呼吸条件下,应用喷射通气辅助下经喉罩行困难气道气管插管安全、有效。     

Initial Experience of Emergency Physicians Using the Intubating Laryngeal Mask Airway: A Case Series

OBJECTIVE: Although the intubating laryngeal mask airway (ILMA) is widely available, its use by emergency physicians (EPs) has not been reported. The authors report the initial experience of EPs using the ILMA. A review of their experience and the relevant anesthesia literature provides a basis for EPs to use the ILMA more confidently and effectively. METHODS: Between January 2000 and January 2001, the ILMA was used on a convenience sample of emergency department (ED) patients undergoing "routine" intubations, and "rescue" situations, after failed rapid-sequence intubation (RSI). Patients were identified from the ED resuscitation case database. Chart review and intubating physician interviews focused on success of the device, complications encountered, and "pearls" of the device's use as perceived by the intubating physician. RESULTS: Ventilation with the appropriate-size ILMA occurred in less than 15 seconds in all "routine" intubations; tracheal intubation was subsequently accomplished in less than 1 minute. Eight of nine "routine" patients had blind tracheal intubation through the ILMA. One patient required fiberoptic bronchoscopy to guide the endotracheal tube into the trachea. Of the "rescue" intubations, all patients (n = 7) were successfully ventilated and five were successfully intubated using the ILMA. CONCLUSIONS: In this case series, the ILMA was easy to use in acute resuscitations, and proved to be invaluable in cases of failed RSI.     

T HE L ARYNGEAL T UBE : A N EW A DJUNCT FOR A IRWAY M ANAGEMENT

Introduction. A prototype of the laryngeal tube was tested for simple and reliable use for ventilation in a mannequin. One possible use of this tube will be the management of the difficult airway. In spite of blind insertion, an inadvertent tracheal positioning should not occur due to the form of the tube. A pharyngeal cuff provides a proximal seal of the airway, while an esophageal cuff seals the airway distally and prevents aspiration of gastric contents. A ventral opening between both cuffs is used for ventilation. Objective. To examine the reliability of the laryngeal tube for airway management in a mannequin. Methods. Fifty physicians and nurses were included in this study and inserted the laryngeal tube blindly during ten consecutive attempts in an advanced life support mannequin. All participants used the laryngeal tube for the first time. Results. During 500 insertions of the tube, correct placement and sufficient ventilation were achieved 478 times in the first attempt (95.6%); 18 times (3.6%), inflating the proximal balloon with an additional 50?mL of air led to sufficient ventilation. In four attempts (0.8%), sufficient ventilation was still not possible due to the tube's not being placed deep enough (according to the printed ring marks on the tube). In each case, the tube was placed correctly in the following attempt. Neither a tracheal intubation nor ventilation of the stomach could be observed. The average time for positioning the laryngeal tube was 27.15 seconds for all 500 attempts (average time of the 50 participants for the tenth attempt: 23.85 seconds). Conclusion. The laryngeal tube may be a fast, reliable, and easy device for airway management. Further research is necessary.     

The intubating laryngeal-mask airway may be an ideal device for airway control in the rural trauma patient

A review of the literature on advanced airway management indicates that the intubating laryngeal-mask airway (ILMA) may be an ideal device for airway control in the rural trauma patient. The ILMA is an advanced laryngeal-mask airway designed to allow oxygenation of the unconscious patient as well as blind tracheal intubation with an endotracheal tube. The ILMA is an easy-to-use airway with a high success rate of insertion, and requires little training. For the rural physician managing a difficult airway in a trauma patient, the ILMA has been found to be reliable and successful when other techniques fail, such as fiberoptic intubation and direct laryngoscopy. The ILMA has also been reported to cause less hemodynamic change and less injury to the teeth and lips than direct laryngoscopy. Further, the ILMA was found to be easier and faster to use with a higher success rate than either the combitube or endotracheal tube for unskilled healthcare providers. Limitations and complications of the ILMA may include aspiration, esophageal intubation, damage to the larynx or other tissues during blind passage of a tracheal tube, and edema of the epiglottis.     

Fiberoptic-Guided and Blind Tracheal Intubation Through iLTS-D,Ambu® Auragain™, and I-Gel® Supraglottic Airway Devices: A Randomized Crossover Manikin Trial

BackgroundThe use of supraglottic airway devices (SADs) is becoming more widespread. However, there is little evidence to show which device is best in an emergent clinical scenario.ObjectiveWe compared both fiberoptic-guided and blind tracheal intubation through the Intubating Laryngeal Tube Suction-Disposal (iLTS-D), the AuraGain™, and the i-gel® in an airway manikin.MethodsThirty residents were included in a randomized trial to perform both fiberoptic-guided and blind tracheal intubation using the iLTS-D, the AuraGain, and the i-gel. The main endpoint was the total time taken to achieve successful fiberoptic intubation through the SAD. Additional endpoints included total time for blind intubation, SAD insertion time, tracheal tube insertion time, intubation success rate, fiberoptic view, and maneuvers performed to achieve tracheal intubation.ResultsAll participants performed fiberoptic intubation using all three SADs on the first attempt. The total time to fiberoptic tracheal intubation using the i-gel, AuraGain, and iLTS-D was 42 s, 56 s, and 56 s, respectively. The blind tracheal intubation success rate was 80% with the iLTS-D, 43% with the i-gel, and 0% with the AuraGain. The total time for blind tracheal intubation through the i-gel and the iLTS-D was 29 s and 40 s, respectively. Laryngeal view grades were significantly poorer with the iLTS-D compared to the other devices. The iLTS-D required significantly more maneuvers to achieve successful tracheal intubation.ConclusionsIn an airway manikin, the iLTS-D, AuraGain, and i-gel appear to be reliable devices for airway rescue and fiberoptic-guided tracheal intubation. The iLTS-D is recommended for blind tracheal intubation.     

The Intubating Laryngeal Mask Airway: Suggestions for Use in the Emergency Department

With the increased use of rapid-sequence induction and its potential complications, emergency physicians need a rescue device for unexpected difficult intubations. The intubating laryngeal mask airway (ILMA) is an ideal rescue airway since it can be placed quickly and can provide adequate ventilation in nearly all patients. It can then be used as conduit for endotracheal intubation, while ventilation is ongoing. The authors review the current literature on the ILMA. In conjunction with their experience using the ILMA in the emergency department (ED), a modification of the American Society of Anesthesiologists difficult airway algorithm was derived for use in the ED. The ILMA appears to be valuable for managing difficult airways.     

Emergency Endotracheal Intubation With a Rigid Stylet of an Infant With Severe Subglottic Stenosis

BackgroundSubglottic stenosis is a frequent complication of endotracheal intubation in children and can create a difficult airway situation for subsequent respiratory illnesses. Difficult airway algorithms are an essential aid when dealing with respiratory failure in clinical situations where ventilation or intubation is unsuccessful.Case ReportA 4-month-old infant with a history of previous endotracheal intubation required endotracheal intubation for stridor and respiratory failure due to croup. There was difficulty intubating the trachea due to severe subglottic stenosis that developed following the previous episode of endotracheal intubation. Successful intubation was facilitated by the use of a rigid endotracheal tube stylet to facilitate passage of an endotracheal tube through the stenotic segment.Why Should an Emergency Physician Be Aware of This?Difficult airway algorithms recommend the use of invasive airway access only as a last resort and noninvasive airway access should be explored prior to their use. The use of a readily available rigid stylet as an alternative method for tracheal intubation should be considered only after more conventional techniques and potential complications have been considered.     

The triple work-up for emergency department patients with acute chest pain: how often does it occur?

Background: In 2005, the European Resuscitation Council and the American Heart Association published new guidelines for Advanced Life Support. One of the points was to reduce the time without chest compressions in the first phase of cardiac arrest. Objective: We evaluated in a manikin model whether using the single-use laryngeal tube with suction option (LTS-D) instead of endotracheal intubation (ET) and bag-mask-valve ventilation (BMV) for emergency airway management could reduce the “no-flow time” (NFT). The NFT is defined as the time during resuscitation when no chest compressions take place. Methods: A randomized, prospective study was undertaken with 150 volunteers who performed management of a standardized simulated cardiac arrest in a manikin. Every participant was randomized to one of three different airway management groups (LTS-D vs. ET vs. BMV). Results: The LTS-D was inserted significantly faster than the ET tube (15 s vs. 44 s, respectively, p < 0.01). During the cardiac arrest simulation, establishing and performing ventilation took an average of 57 s with the LTS-D compared to 116 s with ET and 111 s with the BMV. Using the LTS-D significantly reduced NFT compared to ET and the BMV (125 s vs. 207 s vs. 160 s; p < 0.01). Conclusions: In our manikin study, NFT was reduced significantly when the LTS-D was used when compared to ET and BMV. The results of our manikin study suggest that for personnel not experienced in tracheal intubation, the LTS-D offers a good alternative to ET and BMV to manage the airway during resuscitation, and to avoid the failure to achieve tracheal intubation with the ET, and the failure to achieve adequate ventilation with the BMV.     

Comparative Study of Airway Management Techniques with Restricted Access to Patient Airway

Objective. To determine which airway endotracheal tube (ET), Combitube (CT), or Laryngeal Mask Airway (LMA) has the shortest time to successful ventilation in three nontraditional prehospital airway scenarios. Methods. Prospective randomized cohort study of emergency medicine (EM) residents, faculty EM physicians, andparamedics (EMT-P). Subjects were instructed to place an airway in a mannequin in three scenarios: mannequin supine under a table with head abutting a wall, mannequin sitting upright with access from behind, andmannequin lying on its side with access facing the mannequin. The number of airway placement attempts andtime to successful ventilation were recorded. Results. Twenty-five resident physicians, 9 faculty physicians, and22 EMT-Ps participated. No significant difference was found between the different airways in the number of attempts to successfully ventilate. EMT-Ps demonstrated significantly faster times to successful ventilation for all scenarios versus physicians (e.g., supine scenario with ET, EMT-P median time 57 seconds, physician median time 96 seconds) except for the mannequin lying on its side where there was no significant difference. The time to ventilation for all scenarios was less with the LMA versus ET or CT versus ET, except in the sitting scenario where ET andCT were comparable Conclusions. In this mannequin model of restricted airway access, LMA resulted in significantly faster times to ventilation versus ET andCT in all but one scenario. Further consideration andstudy using airways other than ET are warranted for situations with restricted access to the patient's airway.     

Use of the intubating laryngeal mask airway by medical and nonmedical personnel

The intubating laryngeal mask airway (ILMA) is a newly available device designed to allow for blind endotracheal intubation and treatment of patients with difficult airways. We studied the intubation success rates and speed with initial use of this device on an intubation manikin to determine whether this device might be easily used by trained and untrained personnel. Rapid and successful intubation with a device requiring limited or no training could have widespread implications for both health care providers and laypersons. The study consisted of 2 parts. In part 1, health care providers with intubation experience, health care providers without prior intubation experience, and nonmedical personnel were instructed to enter a room and intubate a manikin using the ILMA. A single page set of schematic directions was provided within the ILMA setup. The main outcomes were the intubation success rate and the time required for successful ventilation and intubation. In part 2, participants were retested after a standardized <60 second device demonstration. The 111 participants in the study included 44 emergency physicians (40%), 21 anesthesiologists (19%), and 46 other medical or nonmedical personnel (41%). On first attempted use of the device, and with no prior training, 59% of all participants successfully intubated the manikin. Attending and resident physicians had an 83% initial success rate. The median time to ventilation was 47 seconds, and the median time from ventilation until intubation was 29 seconds. Following the <60 second demonstration, 108 of 111 (97%) participants achieved success, with the median time to ventilation 18 seconds, and the median time from ventilation until intubation 17 seconds. All attending and resident physicians succeeded in intubation following the demonstration. Success rates on first attempt correlated with level of training, prior intubation experience, and prior LMA use (all P < .001). After a <60 second demonstration, medical and nonmedical personnel with and without prior intubation training can successfully use the ILMA to rapidly establish an airway in a manikin model. The ILMA should be further studied to determine if it may permit endotracheal intubation by first responders, paramedical personnel, and other medical staff with limited or no laryngoscopy skills.     

Emergency Department Vacuum Extraction of an Obstructing Tracheal Foreign Body Using a Meconium Aspirator and Modified Endotracheal Tube

BackgroundA meconium aspirator is a simple plastic adapter that allows for rapid suctioning of the trachea when attached to an endotracheal tube and a source of continuous negative pressure, as was historically done for suspected neonatal meconium aspiration. Adaptation of this technique for the emergent vacuum extraction of an obstructing tracheal foreign body in an adult has not been previously described.Case ReportWe report the case of a 33-year-old woman with cardiorespiratory arrest after choking on food. Complete tracheal obstruction precluding oxygenation and ventilation due to aspirated chicken was diagnosed by emergency physicians and managed immediately with vacuum extraction using the technique described in this report. No additional airway interventions were necessary and the patient made a full neurologic recovery.Why Should an Emergency Physician Be Aware of This?Vacuum extraction using a meconium aspirator and modified endotracheal tube is a novel and potentially life-saving approach to the emergency management of airway obstruction after choking, especially if the foreign material is below the vocal cords and not amenable to manual extraction with a Magill forceps.     

Comparison of Video,Optical, and Direct Laryngoscopy by Experienced Tactical Paramedics

Abstract

Objectives. While optical and video laryngoscopy have been studied in the emergency department, the operating room, and the routine prehospital setting, their efficacy in the tactical environment—in which operator safety is as important as intubation success—has not been evaluated. This study compared direct laryngoscopes to optical (AirTraq) and video (King Vision) laryngoscopes in a simulated tactical setting. Methods. This prospective institutional review board-approved simulation study evaluated each of the laryngoscopes in the hands of seven experienced tactical paramedics. After a one-hour training session, each tactical paramedic used each of the laryngoscopes, in a random order, on each of four different airway manikins. A tactical environment was simulated using auditory and visual immersion, and the intubations occurred on the ground with the paramedics in full tactical gear. Outcomes included time to successful ventilation, first-pass success rate, Cormack-Lehane grade, and intubator head height during the intubation. Statistical analysis included chi-squared and Wilcoxon rank sum tests, and multivariate logistic regression was performed to determine contributing factors to outcomes with significant variation. Results. A total of 84 intubations were performed by seven tactical paramedics. While there were no significant differences in time to successful ventilation or first-pass success rate, the optical and video laryngoscopes had significantly better Cormack-Lehane grades, defined as grade I or II (100% for both compared to 85.7%), while direct laryngoscopy resulted in significantly less maximum vertical exposure of the intubator (51.82 cm compared to AirTraq's 56.64 cm and King Vision's 56.13 cm). Conclusion. Video and optical laryngoscopes can be used successfully by experienced tactical paramedics in a simulated tactical setting. The King Vision and AirTraq resulted in improved Cormack-Lehane glottic views but similar times to ventilation and first-pass success compared to direct laryngoscopy. Intubator head height was lower with direct laryngoscopy. Clarifying the role of optical and video laryngoscopes in a tactical environment, especially in the hands of less experienced intubators, requires further research.     

A Global Vision of Prehospital Care

Abstract

Background. Out-of-hospital tracheal intubation is controversial because of questions regarding its safety as well as its impact on patient care. Factors contributing to the controversy include failed intubations, number of attempts required, prolonged periods without ventilation, and misplaced tracheal tubes. However, the most important factors are the decision-making and clinical skills of the intubator. Unfortunately, the limited number of outcome studies adds to the controversy. New technology, the video laryngoscope, has been introduced to facilitate tracheal intubation. At least one model of video laryngoscope (GlideScope Ranger) has been designed for out-of-hospital use. In an effort to assess the effect this technology might have on out-of-hospital intubation, a study comparing traditional laryngoscopy (TL) versus video laryngoscopy (VL) was performed. The study endpoint was the number of attempts to achieve intubation. Data were also collected on time to intubate, nonventilated periods, unrecognized misplaced tubes, and complications of the procedure. Methods. Data were collected on 300 consecutive patients, 6 years of age or older, weighing at least 20 kg, who were intubated using TL. They were compared with data on 315 patients who were intubated using VL. All intubations were confirmed by visualization where possible, auscultation, misting, and capnography. In addition, all were continuously monitored by capnography. Results. The average time to intubate in the VL group was 21 seconds (range 8–43 seconds) versus 42 seconds (range 28–90 seconds) in the TL group. The average number of attempts was 1.2 (range 1–3) in the VL group versus 2.3 (range 1–4) in the TL group. Successful intubation was 97%% in the VL group versus 95%% in the TL group. There were no unrecognized misplaced tubes in either group. For failed intubations, an alternative airway was successful in 99%% of the VL group and 99%% of the TL group. Maximum nonventilated time during any one intubation attempt was 37 seconds in the VL group and 55 seconds in the TL group. Conclusions. The numbers of attempts were significantly reduced in the VL group. This suggests that the use of VL has a positive effect on the number of attempts to achieve tracheal intubation.     

Comparison of Airway Management Methods in Entrapped Patients: A Manikin Study

Introduction: Endotracheal intubation remains one of the most challenging skills in prehospital care. There is a minimal amount of data on the optimal technique to use when managing the airway of an entrapped patient. We hypothesized that use of a blindly placed device would result in both the shortest time to airway management and highest success rate. Methods: A difficult airway manikin was placed in a cervical collar and secured upside down in an overturned vehicle. Experienced paramedics and prehospital registered nurses used four different methods to secure the airway: direct laryngoscopy, digital intubation, King LT-D, and CMAC video laryngoscopy. Each participant was given three opportunities to secure the airway using each technique in random order. A study investigator timed each attempt and confirmed successful placement, which was determined upon inflation of the manikin's lungs. Intubation success rates were analyzed using a general estimating equations model to account for repeated measures and a linear mixed effects model for average time. Results: Twenty-two prehospital providers participated in the study. The one-pass success rate for the King LT-D was significantly higher than direct laryngoscopy (OR 0.048, CI 0.006–0.351, p < 0.01) and digital intubation (OR 0.040, CI 0.005–0.297, p < 0.01). However, there was no statistical difference between the one-pass success rate of the King LT-D and CMAC video laryngoscopy (OR 0.302, 95% CI 0.026–3.44, p = 0.33). The one-pass median placement time of the King LT-D (22 seconds, IQR 17–26) was significantly lower (p < 0.001) than direct laryngoscopy (60 seconds, IQR 42–75), digital intubation (38 seconds, IQR 26–74), and the CMAC (51 seconds, IQR 43–76). Conclusions: In this study, while the King LT-D offered the quickest airway placement, success rates were not significantly greater than intubation using the CMAC video laryngoscope. Intubation using direct laryngoscopy and digital intubation were less successful and took more time. Use of a blindly placed device or a video laryngoscope may provide the best avenues for airway management of entrapped patients.