Backup airways: which to keep in the ALS bag?

[tniuqs]

In My HOOD we tried so hard to actually be allowed to shoot an ETT, yet now I see an alarming trend to use rescue devices first, really it comes down to confidance and competency so one does NOT have to go this route at all.

The ETT remains the definitive gold standard, bar none.

cheers

[irme]

Everybody states that the ETT is the gold standard, why is that?

I am currently doing a case study on the combi tube and if i didnt read the success stats i would wonder how someone can not get it right if fully trained..

[chbare]

Irme, you need to appreciate how the ETC functions. It is a supraglottic device. In most cases, the distal tube will be placed into the esophagus while the proximal portion occludes the upper airway. This in theory will only allow air to flow through the glottis. Sounds like the next best thing to sliced bread (shameless cliche).

However, lets throw in laryngeospasm, angioedema, an airway burn, or perhaps a COPD patient with high peak airway pressures. I hope you will be able to appreciate the pit-falls of the ETC. While it may work for most of our patients, many patients will require a cuffed tube in the trachea.

With that said, the concept of "I will never miss the tube because I am excellent at intubation" is great in theory; however, reality dictates we plan for the worst. We must realize that in some cases, no amount of skill will produce the intended outcome. The ETC is a rescue device and should be utilized as such.

Take care,

chbare.

[irme]

Irme, you need to appreciate how the ETC functions. It is a supraglottic device. In most cases, the distal tube will be placed into the esophagus while the proximal portion occludes the upper airway. This in theory will only allow air to flow through the glottis. Sounds like the next best thing to sliced bread (shameless cliche).

However, lets throw in laryngeospasm, angioedema, an airway burn, or perhaps a COPD patient with high peak airway pressures. I hope you will be able to appreciate the pit-falls of the ETC. While it may work for most of our patients, many patients will require a cuffed tube in the trachea.

With that said, the concept of "I will never miss the tube because I am excellent at intubation" is great in theory; however, reality dictates we plan for the worst. We must realize that in some cases, no amount of skill will produce the intended outcome. The ETC is a rescue device and should be utilized as such.

Take care,

chbare.

Excellent thanks for that info, will slot beautifully into my case study!

[mediccjh]

Combi-tube. Only 2 sizes, so less room to take up in the bag.

[flightmedic46]

Everybody states that the ETT is the gold standard, why is that?

Intubation saves lives! How many people are walking around out there today after you've crammed one of these rescue airways down their throat?? Mabe a few isolated cases. More and more case studys are coming out proving that absoluty nothing we do in the field is making a difference in severe trauma pt outcome. Only Speed (time to surgery) and early intubation.

[AZCEP]

Tracheal intubation has not shown to be particularly valuable for managing trauma, medical, pediatrics, or cardiac arrest situations. By itself, it will not improve anything. Combined with the inability of most to correctly ventilate once the airway is secured, you quickly run into good reason to disallow the procedure.

Gold standard or not, when providers don't perform enough to remain competent in the procedure, there is no reason to allow everyone to use it. Especially when rescue devices are just as effective for the short term, and are placed before the airway is full of fluid/foreign bodies that poor intubation technique introduce.

[Scaramedic]

Part of the problem with ETI is so many Medics are quick to drop that tube when other measures might be more effective. A simple adjunct such as an OPA is sometimes all a patient needs. Unfortunately an OPA is just not as "Johnny and Roy" to a lot of Medics.

Personally I try to avoid ETI as much as possible. Luckily I have worked in busy systems which still means I'll probably be dropping numerous tubes a week anyway. Some cases were a tube can be essential: burns with airway compromise, allergic reactions where the airway is quickly being lost, unresponsive puking patients and severe bleeding compromising the airway. That is just a small list of the top of my head.

I was taught start small and work up, try the simple adjuncts before you pick up that laryngoscope. If you have to argue with the patient about whether or not they need a tube, they probably don't need it (at least not yet).

Peace,

Marty

[tniuqs]

Tracheal intubation has not shown to be particularly valuable for managing trauma, medical, pediatrics, or cardiac arrest situations. By itself, it will not improve anything. Combined with the inability of most to correctly ventilate once the airway is secured, you quickly run into good reason to disallow the procedure.

Gold standard or not, when providers don't perform enough to remain competent in the procedure, there is no reason to allow everyone to use it. Especially when rescue devices are just as effective for the short term, and are placed before the airway is full of fluid/foreign bodies that poor intubation technique introduce.

Firstly I have no idea where you have come to the conclusion that ETT (protecting an Airway is anything less that Definitive Care) many studies prove without exception that capture of the airway and control over the airway IS exactly the diference between survival and death. If your opinion was the truth why would we even bother to Intubate in OR or ICU, 75% of patients in the majority of cases due to complications of aspiration and resultant pneumonias, sorry to disagree with your opinion but it is seriously groundless. NONE of these rescue devices have claim to this, besides if your on the recieving end of a patient it is a serious complication to Intubate after any of these devices are used, and damn hard to set up a ventilator to ventilate these micky mouse airways, just try doing a Bronchoscopy via the LMA or Combi to suck out the peas and carrots, EMS SHOULD be part of the continuing cascade of care in health care..... not make it more complicated.

Your assumption that most do not know how to ventilate nor preform this typically "monkey skill" set is frankly rather scary as these skills SHOULD be taught properly from the Educators themselves from the start. One could in conclusion, state that the Educators are the problem not the students....if one would want to go that far down that road. This is a very dark road that Paramedics should be disallowed what your forefathers fought for years to gain approval and advance Paramedicine.

AZCEP: Your confusing comptency with a tecknique and devices made to compensate for lack of practice or skills....apples and oranges man, besides not all practitioners are short term care this is an assumtion as well, unless a 6 hour flight or 3 hour drive is considered short.

[VentMedic]

Part of the problem with ETI is so many Medics are quick to drop that tube when other measures might be more effective. A simple adjunct such as an OPA is sometimes all a patient needs. Unfortunately an OPA is just not as "Johnny and Roy" to a lot of Medics.

Marty

If a patient is tolerating an OPA, they need a definitive airway such as an ETT. An OPA is not to be left in the patient for any length of time due to aspiration risks. It is used primarily when using the BVM until ETI is performed. It is also not to be left in after ETI unless absolutely necessary or you have no other tube guard to protect against clenching teeth.