Back up Airway Devices; the Good, the bad, and the Ugly.

[chbare]

This may be a redundant thread, however, I am curious to see what experiences people have had using the various airway back up devices. I have read threads where people say, "I hate LMA's" or "I have had good experiences with the combi tube." I want to expand and see how people have used these various devices. How did they work, what problems/complications developed, were they used in a unique way,(ie; used an LMA proseal and put a bougie down the gastric tube to facilitate better placement) and how did the pt do after it was all said and done? This question is with the knowledge that an ETT properly placed is the gold standard for airway management.

Take care,

chbare.

[AZCEP]

The Combitube works pretty well if it is placed early, not so well if you wait until a couple of oral intubation attempts are made. Once the oropharynx is torn up, the cuffs just don't seal too well. If you are able to get them to seal, now you have to deal with the blood draining directly into the trachea.

Use it early, or not at all.

[chbare]

AZCEP, you bring up a good point. The combitube does not prevent upper airway (oropharynx) secretions from draining into the trachea if the distal tube is in the esophagus. These devices are supraglottic as well, so pathology below or at the glottis could render these devices useless. (ie; burns, swelling, lower airway obstruction, laryngeospasm) A neat thing occured in my ER last week while I was out. I was told today about a scenario that occured a couple of days ago. A critical patient was seen in the ER and he was prepped for transfer. The flight team arrived and decided to intubate, but could not get the tube in and lost the airway. The ER charge nurse decided to call anesthesia when she noticed the team starting to have problems. An Intubating LMA was placed, and anesthesia was able to place an ETT via the ILMA and rescue the patients airway. I do not know the specific details of this scenario, privacy issues you know. It sounds like the nurse made a good call. No spell check avaliable, I hope my spelling is not too bad.

Take care,

chbare.

[brock8024]

I personally like the LMA. When I done my OR clinicals the doctors showed me different ways of putting them in and things. I got use to them and like them. They are not the best because they do not help prevent vomit but as a back up it works well.

Brock

[Ridryder 911]

I personally have never used LMA in pre-hospitql environment, but; from all the stories I heard, they are easy to use however; they dislodge too easy, for the rigorous environment we work in. Like to see more studies and reviews on other alternate airways.

Be safe,

R/r 911

[chbare]

Brock8024, I also think the LMA is easy to insert, and this is comming from a nurse, so it must be easy to use. Ridryder 911, I agree with you on the LMA. It is a very fickle device when it comes to staying put. I saw a few case studies on the ILMA, and it seems like it may be a little more stable, and I must say I have been impressed with the results of using it in the static(ish) hospital environment. Initial success with the device was only in the 80% range, (passing the ETT) but with use of the Chandy technique I believe success is in the upper 90 percent. Again, who knows if this can be applied to the prehospital environment. I have had very good experiences with the combitube, and virtually every prehospital combitube that I have seen provided an adequate airway, adequate ventilation, and did not easily dislodge. However, combitubes are a pain to intubate around at best. Nothing replaces the good old properly placed ETT. I have heard that alternative airways are commonly used over seas, (UK & Europe) it would be nice to hear from EMS workers in these countries about their experiences. More prehospital research is needed. If only EMS was more involved as a profession and had Phd programs, I bet we would get allot more pre hospital resaerch done by EMS professionals.

??No spell check, my true idiot colors are showing!!

Take care,

chbare.

[fireflymedic]

Hey,

LMA's are okay, though they do not prevent aspiration well at all. That is their biggest problem. Combi-tubes are a good thing, and truthfully in a code type situation, they are better than nothing. It gives a basic a better airway until ALS can arrive. The one airway substitute that I have fallen in love with is the king tube. It is very similar to an ETT except that it is a blind insertion and acts much like a combi-tube, but only one balloon to inflate, there is sizing similar to an ETT, unlike combi which just comes small and regular. Tenn has approved them on trucks for both basics and medics, and so far all I have talked to, like them as well as I do. Nice device. Definitely gives a more secure airway and doesn't become dislodged as easy as combi-tube. Also, very easy to intubate following placement (though I believe if you have a good airway in place and no signs of aspiration or indication to intubate, just leave what's there!) I think they are superior to anything out on the market right now, but that is solely my opinion, take it for what it is worth (somewhere around 2 cents I believe). Also, they are more cost effective than combi tubes or LMA's. As far as intubating, great trick someone showed me (though I am sure it is commonly known) is if the first time you get the esophagus, just leave that tube in place, then try again. You only have one hole to hit. Makes it easier. It really does work. Anyhow, happy airways.

[chbare]

Fire_911medic, thank you for the info on the King. It looks like a great backup device. I did a thread on it earlier and Spock a CRNA on this site had good things to say about the King as well. Have you had a chance to insert a bougie through the King and then intubate with the bougie? I hear this is something that you can do with the King.

Take care,

chbare.

[fireflymedic]

C,

Everytime I have dealt with the king, it has been as a primary device. Usually placed by a BLS crew prior to arrival. I've never tried the method you mentioned. I'd be curious to see how it worked. We don't have that much exposure with them in my area (though I did get limited exposure during my clinical time), as they are not approved in my state. However, a service I worked for previously frequently ran ALS intercept, or was even the primary response for a local service directly across the state line as they were frequently understaffed or overtaxed. It was a great mutual aid agreement. I had to have certs though for both states as well as holding my cert for ohio and alabama, so I've gotten to see alot of different things used in different states. I wish we would get them more in my area as opposed to just in the hospital setting as is now. Thanks for the thought. Have to ask some of my southern friends if they've tried it.

[chbare]

Fire_911medic, I know what you mean. If it works why mess with it? I remember when I first started working ER we would get allot of EMS patients with combitubes. At the time our towns service was a BLS/ILS service and all codes got a combitube. I remember the first "combitubed" patient I helped take care of as an RN. My nurse preceptor and the ER doc told me that combitubes were crap as EMS rolled the patient into the ER. Then to my shock and horror I saw the nurse grab both pilot balloons take out her scissors and cut the ports off just below the level of the balloons. She then yanked the combitube out and the ER doc intubated the patient. Now if a patient comes into the ER and a working combitube is placed, I guard that thing with my life. The ER doc can intubate around the tube or if we are working with a medic he/she can try to intubate around it. If the combitube was placed related to a failed airway, anesthesia gets a call and the surgical airway supplies come out of hiding.

Take care,

chbare.