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

[Spock]

I stayed out of this topic for a few days in order to give other folks an opportunity. I have experience with all of the devices mentioned so I'll offer some thoughts in no particular order.

Endotracheal intubation is still the gold standard although there has been research done that is sharply critical of paramedic intubating skills. If you are not aware of this literature you should educate yourself because there are some physicians who would like to see intubation removed from the paramedic's arsenal.. Also, I feel that if you do not have wave form capnography available in your truck you should not be intubating anyone.

One thing 4-5,000 intubations has taught me is that not everybody can be intubated and one or two backup devices are necessary. We use the LMA in the operating room. If we anticipate a difficult intubation we either use an intubating LMA or do an awake fiberoptic intubation. The ILMA is much easier and less time consuming but does take a certain amount of practice to maintain proficiency and it is not always successful. If I've gone a few weeks without using an ILMA I will use one electively in order to maintain my skill. Awake FOI requires even more skill and practice and is actually becoming a lost art since the advent of the ILMA.

I don't necessarily agree that the LMA is easy to place. I felt the learning curve was about 25 because that was how many it took before I was comfortable. Perhaps I'm a slow learner! Also, just like ETI, there are some patients that can't be ventilated with an LMA. We use the regular LMA for simple cases where a general anesthetic is required and it works well. As people have mentioned, losing the seal with an LMA is easy and I feel this along with its inability to prevent gastric aspiration are the biggest drawbacks to prehospital use. The LMA is available in disposable and reusable models. Sizes range from pediatric #1 up to #6 (giant size). Sizes are based on weight. I guess I've put in 8-900 LMA's.

My experience with the combitube is limited to intubating around it in the ER. The combitube is the only backup device approved in PA and we have seen it several times in the ER. I had to do an in service for my anesthesia department on how to change a combitube after the first time one came through the doors because nobody had ever seen one although we all had heard of them. The ER calls anesthesia when they get word a combitubed patient is on the way because they figure it is a difficult intubation and they punt it to us. The most important part is to decompress the stomach with the suction catheter provided in the kit before removing the combitube. The manufacturer has a recommended procedure for removing the combitube.

Now to my favorite backup the King LT-D. the King came to the USA from Germany in 2005. We added it to our department a few months ago and I've used it 12 times so far. I've used it for cases where I would normally have used an LMA. I feel the learning curve is zero. The first person to use one in our department was a first year SRNA. She had no problem with it. It maintains a good seal when moving the patient. The sales rep put one into a mannequin head and was able to pick the head off the table by the holding the King which was not secured with tape. It provides a small amount of protection against gastric aspiration and you can ventilate with a higher amount of positive pressure than an LMA (30 cm H2O vs 20 with the LMA). I feel it is so easy to use that if an EMT can place an OP airway he/she can place a King LT-D. You can pass a bougie through a King, remove the King, and then pass an endotube over the bougie into the trachea. We have not done that in our department as of yet but we did run a fiberoptic scope down a King and found the vocal cords directly in line with the opening of the King. If you go to the King website you can view a video of the procedure. I'm at work and don't have the exact website but will post it when I get home tomorrow. The King comes in three sizes: #3, #4, & #5. No pediatric sizes right now. Sizes are based on height.

Now for cost. My hospital pays $1.10 for an endo tube, $8 for a disposable LMA, $14 for a King LT-D (the D is for disposable), about $200 for a reusable LMA, and about $600 for an intubating LMA. We are pushing the King because we want to go to an all disposable system and frankly the disposable LMA's are harder to place than the reusable LMA's.

Sorry to be so long but I hope that helps. I'm interested in your experiences with back up airway devices in the field especially anyone using an LMA routinely. Am I correct about easily losing the seal when moving the patient? Also, I'm working on getting the King approved for use in PA so if your state has approved use of the King please let me know here.

Live long and prosper.

Spock

[chbare]

Spock, thank you for your input. I think the web site you talked about is, www.narescue.com. I agree that end tidal C02 monitoring is crucial. People may think I am crazy, but I thow an easy cap on the end of ever rescue airway I come across. I also advocate using esophageal intubation detector bulbs on the combitube to help identify what tube will be ventilated through. Lung and epigastric auscultation alond with chest rise and fall and tube condensation are not the most reliable assessment methods. The technology is available, and it is criminal not to use it.

Take care,

chbare.

[Ridryder 911]

Good comments Spock, we do appreciate your professional in-put. I too agree with ETC[sub:c15e211778]0[/sub:c15e211778]2. There is no debate, either you have it or don't intubate... this would stop all the madness of "misplaced" tubes.

I would personally like to see and use a "King LT" tube . I had a very difficult intubation the other day, that the only back up airway this service had was an old "EOA" (shutter) and it was still unsuccessful... even the anesthesiologist had a very difficult time intubating her. You are right there are some, that traditional methods are not practical.

As you discussed chbare, condensation and even chest wall movements are NOT reliable assessments. It is time educational and training institutions to STOP teaching this. It has been well documented that it is not reliable, as well as even lung sounds can even be mis-leading.

Hopefully more and better alternative airway devices will be designed for those airways from hell...

R/r 911

[Spock]

The website I was thinking of is www.kingsystems.com

One thing I left out is the cost of a combitube which I believe is around $70. When I mentioned capnography I was thinking specifically of the wave form capnography we have with our Lifepack 12. The easy cap colorimetric CO2 detector has severe limitations which many providers do not recognize. I go ballistic when I roll into a hospital with an intubated patient and show the physician the ETCO2 wave form on my monitor and they then insist on using an easy cap to "confirm" my tube placement. It is another example of prehospital technology outpacing inhospital technology.

PA is working on a final draft for state wide ALS protocols. There was talk of requiring wave form capnography but I don't know if it made into the protocols. Many services would have to spend some money so it may never happen.

Live long and prosper.

Spock

[1EMT-P]

I have been using the Combitube in the field since the early 90's and in my opinion it is a good airway adjunct to have, but it does have age and size limitations. Not to mention the fact that it can be difficult to intubate around.

[chbare]

I was able to use a pediatric combitube at SLAM a couple earlier this month. I am not sure if it is on the market. I would be curious to see any data on it or hear first hand experience if it is being used.

Take care,

chbare.

[asrnj77]

[Now for cost. My hospital pays $1.10 for an endo tube, $8 for a disposable LMA, $14 for a King LT-D (the D is for disposable), about $200 for a reusable LMA, and about $600 for an intubating LMA. We are pushing the King because we want to go to an all disposable system and frankly the disposable LMA's are harder to place than the reusable LMA's. ]

I agree that the King LT-D is great. The military still loves the combitube. However if your hospital is getting King LT-D's for $14.00 they are getting a great deal. www.narrescue.com charges the government $55.00 and has the retail on them at $67.00

[Spock]

I'll double check on our price for the King LT-D. Perhaps the price you saw was for the reusable King LT? Even at $67 that is much cheaper than the reusable LMA.

Live long and prosper.

Spock

[Medic26]

Spock,

I too work in a rural PA region where we have had an ongoing ET study....out of 2-300 intubations so far there have been 2 confirmed misplaced tubes, both by the same medic (discipline issue here). I don't believe that this is as big a problem as some people would like to think.

Wave-form ETC02 monitors are required in the NY state region where I work part-time and I think.....not sure that the entire state is requiring it now for pre-hospital intubations. We have them but not enough for every truck yet, wish the state would mandate this so we could upgrade!!

As far as rescue airway devices, we use the combi-tube with great success. I have seen the King demo and would like to carry this as an additional device with the combitube. What would be even better is to get the state onboard and let us have a study with basic providers placing the king in cardiac arrest patients as we sometimes are 30-45 minutes behind them in the rural areas.

[Spock]

PA is in the process of writing statewide ALS protocols. I just saw the first draft of the airway protocol and it includes the combitube and the King LT as approved backup devices. The drug assisted intubation protocol will include etomidate but it has not been finished as of yet. I'm supposed to get a copy of the first draft for review.

I agree with you Medic 26 that the King would be great for a study for use by BLS providers because I feel it is so simple to use that anybody allowed to insert an OP airway could also place a King. First things first though, we have to get it approved for ALS. Regarding capnography: there is strong sentiment in the medical advisory committee for the state EMS office to require capnography for all ALS units. Cost is a factor but they may give highest priority for the EMS grant program to services purchasing capnography. We are moving forward.

Oh, before somebody suggests otherwise, I have no financial interest in the King LT or it's parent company.

Live long and prosper.

Spock