Backup airways: which to keep in the ALS bag?

[1EMT-P]

I agree that ETI is the standard of care when it comes to airway management, but what about EMS providers who live and/or work in communities where their call volume is low or where they primarily do transports? There are some places here in the US where providers simply do not have access to an OR. For these folks the ECT, King or LMA maybe the best option available.

[jjones1418]

We carry 2 of the alternative airways talked about on our helicopter. We carry the Combitube Reg, Combitube SA, LMA 1, 1.5, 2, 2.5, 3, 4, and 5. Also carry the bougie.

We are switching to the King, so I think the Combitubes are coming off. The LMAs will probably be gone as soon as the King Pediatrics get approved.

I've played around with the King on the difficult airway dummy, and I like that there's only one thing to inflate when you've decided to use the thing. AND, If you want, you can slide the bougie down the King, and swap it out with a tube.

I just like the Bougie though. It's just a good tool.

And earlier, someone said something about not being able to hook a vent up to the Combitube, LMA, or King... I've done it to the combitube more than once, and it works fine. Picked up several patients from a hospital that EMS brought in with the ETC in place and the patient being bagged. Put em on the vent and it worked just fine. Per the King LT website, you can mech. vent a King as well. I haven't tried to do it with an LMA.

J.Jones CC/NREMT-P, FP-C

[fireflymedic]

I would go with King tubes all the way, simplicity of an ET tube with the function of a combitube. A single balloon to inflate, MEANT to be blindly inserted, can't posssibly screw it up, it's fantastic. Where I'm at. we are just introducing them onto the trucks, and with all positive results. You still run into the same issue with the King as you do a combi tube - just small adult, not really a pedi size. It's a great replacement for basic services against the combitube and a great addition to an ALS service. I first got to use them when practicing in TN, and fell in love with them bugging my med director here until he pushed the state to let us have 'em. Of course, nothing is as secure as a properly placed and secured ET tube, however, when you have those no neck patients or really anterior airways that you can't get to save your life (or theirs for that matter), it's a great back up.

[Dustdevil]

I would go with King tubes all the way, simplicity of an ET tube with the function of a combitube. A single balloon to inflate, MEANT to be blindly inserted, can't posssibly screw it up..

I honestly have no experience or exposure to this here newfangled King thinger, so I ask sincerely; is it absolutely, positively, beyond any doubt whatsoever idiot proof? I mean, they said that about the Combitube, and the EOA before that, as well as a plethora of other drugs and devices that we put in the hands of idiots, only to watch them kill people with them. So you are saying that the King is perfectly benign? It won't rip the cords or blow out an esophagus when an excited, adrenaline pumped, low experience EMT who has never had a real A&P class, and only a few hours of lab training with a dummy, jams it in there and overinflates it? Yes, I know this is the ALS forum, but we all know that some idiot of a medical director somewhere is going to give these to his EMTs, so the question is relevant.

I'm not a huge fan of the Combitube, but it's what I've got here as a back-up, so I work with what I've got. If there is significant benefit to the King over the Combitube, I want to hear about it. Not that big a deal, though. Mostly I will stick with the "go big or go home" school of thought. If I can't tube em, they're getting a crich.

[fiznat]

As I'm sure you know Dust, nothing is truly idiot proof.

Let's have a look at it though:

It does seem simpler. Only one port to ventilate into, only one port to inflate through. It may be just the perspective but it does seem smaller than the combitube, so perhaps the chance of laryngeal damage is lower. I also like that there is no latex.

[akroeze]

How rigid is the material?

[chbare]

It shares many of the same pitfalls of the ETC. Yes, you can still cause damage if you cram the device into the airway. The tube is rigid much like an ETC or ETT.

Some of the potential benefits over the ETC:

-Only one port for inflation. So, you need not remember what blue #1 and white #2 mean.

-Only one port for ventilation. Again, this leads to less confusion.

-The new Kings have a built in gastric port and you would have extreme difficulty using it to ventilate. (If you were in a hurry and forget that the connector end of the tube fits the BVM.)

-The king has somewhat of an elliptical shape that ensures placement into the esophagus. As I understand, people were unable to place the king into the trachea using laryngeoscopy. However, I would never say never.

-A bougie can be placed through the King and you can attempt a device change out with an ETT provided you place the bougie into the trachea.

-The King seems to work with lower inflation pressures. This may prevent trauma and tissue necrosis. The distal end of the King has a blunt tip that is much softer than the ETC, so this may lead to a decrease in trauma as well.

-The king can provide ventilation with airway pressures over 30 cm/H20.

Overall, I can see several advantages. The King does come in different sizes and you need to inflate the king with a specific amount of air depending on the size.

I would not call it idiot proof, but I would say it is nearly Nurse proof.

Take care,

chbare.

[captainstandup]

My impression of the LMA is that, although routinely used in OR, they are poorly suited for the degree of patient movement encountered in the prehospital environment. I still remember the prehistoric days of the ill conceived EOA. How many patients were killed by those things?

Airway management = Appropriate use of BVM in conjunction with an OPA or NPA and proper technique followed by ETT intubation with ET CO2 and SpO2 monitoring along with frequent reassessment and if time and condition permit insertion of an NG/OG tube just to keep things tidy in the rig and the uniform clean. Utilization of a cervical collar or at least head immobilizer for stabilization and to prevent displacement.

Backup should include, again in my opinion, a combitube, surgical cric (with three way spreader) and finally the godforsaken and quite useless needle cric kit.

I suppose any airway beats "no airway", unless of course I'm the patient and it looks like I may wind up in a damn nursing home. In the latter instance please provide me with two large bore IV's 1000 mics of fentanyl, 50 mg versed, 100 of MS, 5 mg ativan, a nice 100 ml bolus of diprivan, 25 mg vecuronium, 2 grams lidocaine (rapid IV push) and please take about a three hour break.

[Medic26]

Some more info on the King for Dust and others, maybe this will help some:

USER TIPS

1. The key to insertion is to get the distal tip of KING LT-D around the corner in the posterior pharynx, under the base of the tongue. Experience has indicated that a lateral approach, in conjunction with a chin lift, facilitates placement of the KING LT-D. Alternatively, a laryngoscope or tongue depressor can be used to lift the tongue anteriorly to allow easy advancement of the KING LT-D into position.

2. Insertion can also be accomplished via a midline approach by applying a chin lift and sliding the distal tip along the palate and into position in the hypopharynx. In this instance, head extension may also be helpful.

3. As the KING LT-D is advanced around the corner in the posterior pharynx, it is important

that the tip of the device is maintained at the midline. If the tip is placed or deflected laterally, it may enter into the piriform fossa and the tube will appear to bounce back upon full insertion and release. Keeping the tip at the midline assures that the distal tip is properly placed in the hypopharynx/upper esophagus.

4. Depth of insertion is key to providing a patent airway. Ventilatory openings of the

KING LT-D must align with the laryngeal inlet for adequate oxygenation/ventilation to occur. Accordingly, the insertion depth should be adjusted to maximize ventilation. Experience has indicated that initially placing the KING LT-D deeper (base of connector is aligned with teeth or gums), inflating the cuffs and withdrawing until ventilation is optimized results in the best

depth of insertion for the following reasons:

It ensures that the distal tip has not been placed laterally in the piriform fossa.

With a deeper initial insertion, only withdrawal of the tube is required to realize a

patent airway. A shallow insertion will require deflation of the cuffs to advance the tube farther (several added steps).

As the KING LT-D is withdrawn, the initial ventilation opening exposed to/aligned with the laryngeal inlet is the proximal opening. Since this proximal opening is closest to and is partially surrounded by the proximal cuff, airway obstruction is less likely, especially when spontaneous ventilation is employed.

Withdrawal of the KING LT-D with the balloons inflated results in a retraction of tissue away from the laryngeal inlet, thereby encouraging a patent airway.

5. When the patient is allowed to breathe spontaneously, airway obstruction can occur even though no obstruction was detected during assisted or positive pressure ventilation. During spontaneous ventilation, the epiglottis or other tissue can be drawn into the distal ventilatory opening, resulting in obstruction. Advancing the KING LT-D 1-2 cm or initial deeper placement normally eliminate sthis obstruction.

6. Ensure that the cuffs are not over inflated. Especially if the KING LT-D is to be left in place for a period of time, cuffs should be inflated with the minimum volume necessary to seal the airway at the peak ventilatory pressures employed (60 cm H2O, if cuff pressure gauge is available.

7. Removal of the KING LT-D is well tolerated until the return of protective reflexes. For later removal, it may be helpful to remove some air from the cuffs to reduce the stimulus during wake-up.

My experience with using these in practice is that they are far more user friendly and can achieve an airway faster and supposedly safer than a combi-tube.

We have 3 different airway trainers, we were able to intubate with an ETT all 3 on every attempt that we tried using the King and a Boujie stylette. This is much like an intubating LMA.

[chbare]

On an off topic serious note. NG/OG tube placement and gastric decompression can save more than a work uniform. This can actually improve ventilation and oxygenation, decrease insp. pressures, reduce aspiration risk, and score style points.

Take care,

chbare.