Elsevier

Resuscitation

Volume 69, Issue 3, June 2006, Pages 371-387
Resuscitation

Review Article
New airways for resuscitation?,☆☆

https://doi.org/10.1016/j.resuscitation.2005.10.015Get rights and content

Summary

Over the last 15 years supraglottic airway devices (SADs), most notably the classic laryngeal mask airway (LMA) have revolutionised airway management in anaesthesia. In contrast for resuscitation, both in and outside hospital, facemask ventilation and tracheal intubation remain the mainstays of airway management. However there is evidence that both these techniques have complications and are often poorly performed by inexperienced personnel. Tracheal intubation also has the potential to cause serious harm or death through unrecognised oesophageal intubation.

SADs may have a role in airway management for resuscitation as first responder devices, rescue devices or for use during patient extraction. In particular they may be beneficial as the level of skill required to use the device safely may be less than for the tracheal tube. Concerns have been expressed over the ability to ventilate the lungs successfully and also the risk of aspiration with SADs. The only SADs recommended by ILCOR in its current guidance are the classic LMA and combitube. Several SADs have recently been introduced with claims that ventilation and airway protection is improved. This pragmatic review examines recent developments in SAD technology and the relevance of this to the potential for using SADs during resuscitation. In addition to examining research directly related to resuscitation both on bench models and in patients the review also examines evidence from anaesthetic practice.

SADS discussed include the classic, intubating and Proseal LMAs, the combitube, the laryngeal tube, laryngeal tube sonda mark I and II and single use laryngeal masks.

Introduction

Resuscitation is a broad term: for many it brings to mind in-hospital cardiac arrest, but it also includes out-of-hospital episodes including situations encompassing trauma and patient entrapment. Traditionally, the facemask and tracheal tube have been the accepted standards for emergency airway management during resuscitation.1 In anaesthesia, airway management has been revolutionised over the last 20 years by the widespread use of the classic laryngeal mask airway (cLMA). In the last few years, an enormous number of alternatives to the cLMA have also been advocated for use in anaesthesia. These devices are generally known as supraglottic airway devices (SADs). This article examines, broadly, whether SADs have any role or advantages over the traditional methods of airway management during resuscitation. The only SADs mentioned in the 2000 International Liaison Committee on Resuscitation (ILCOR) Guidelines are the cLMA and Combitube.2, 3

Airway management during resuscitation may be divided into three categories:

  • 1

    First rescuer (the first airway device used during resuscitation: ideally a reliable device easily inserted by relatively untrained personnel).

  • 2

    Airway rescue (a back-up device used when other techniques fail).

  • 3

    Specialised (a device used only in specific situations and likely to require specialist skills, e.g. trauma, entrapment).

Individuals whose experience and skill is likely to vary considerably may perform airway management during resuscitation. Recommendations for airway resuscitation equipment should take this into account.

We must first consider what features are important in a device used for airway management during resuscitation. In all cases we need a device that restores and secures the airway rapidly and reliably, allowing oxygenation and ventilation. Further desirable features are permitting positive pressure ventilation, protecting the airway against regurgitation and ‘failing-safe’. Outside the hospital environment, ease of use in circumstances where access to patients may be limited and safety during transfer are important additional considerations. The ‘fail safe’ concept is worth emphasising. A basic precept of medicine is to ‘do no harm’. Devices that cause little or no harm if inexpertly or wrongly used, or simply when they fail, should be favoured over those that can cause harm in these circumstances.

A few general points are relevant. Airway obstruction is common during all critical illness and in particular at cardiac arrest and during trauma.4 Airway obstruction is the fastest way to produce hypoxia and if unresolved will result in irreversible hypoxic brain injury or death within 2–3 min.5 Put simply minutes (even seconds) are a matter of life and death during efforts to establish the airway in resuscitation.

There is evidence that the airway may not be managed well during resuscitation. In-hospital early airway management can be performed poorly and several years ago in our hospital we found that ventilation of the lungs was ineffective in 50% of cases until an anaesthetist arrived at a cardiac arrest.6 In a retrospective study of trauma deaths in the UK there was evidence of airway obstruction in 85% of deaths considered to have been survivable.7 All other resuscitation efforts are futile if airway patency and oxygenation cannot be achieved and maintained. It is also important to note that unrecognised oesophageal intubation and ventilation will result in death, perhaps of someone who would have otherwise survived. Aspiration, although an important consideration, is not universally fatal and therefore avoidance of aspiration is a lesser priority than establishing a clear airway.

Section snippets

Tried and tested devices

There is considerable data relating to several devices: the tracheal tube, bag-valve-mask, the classic LMA and the Combitube. These are discussed first.

Alternatives SADs?

There are many alternatives to the above devices. Few of the devices described below have been evaluated or reported for use in airway resuscitation. They are included because of potential benefits in performance or caveats about their use. Benefits include improved success with ventilation, improved airway protection and specialised roles for trauma, patient extraction and facilitation of intubation.

Others

New SADs continue to be developed and introduced at such a rate that the subject remains very hard to keep up to date with. Other available SADs include the Airway Management Device (AMD), Pharyngeal Airway xpress (PAx), Streamlined Liner of the Pharynx Airway (SLIPA), Cobra Perilaryngeal Airway (CobraPLA) and Elisha Airway Device. At present there is insufficient evidence (or in some cases negative evidence) regarding these devices and the authors do not recommend them for use in

Gastric inflation, and use of Inspiratory Impedence Threshold Valves with SADs

Gastric inflation and its complications will occur with any extraglottic device (i.e. BVM, SAD) that allows gas to leak into the oesophagus during controlled ventilation and CPR. The recommended tidal volumes when using such a SAD should logically be as for BVM. However, it is notable that some SADs are likely to lead to oesophageal leak during ventilation (e.g. cLMA), some are known to be less likely to (e.g. PLMA, Combitube) but for many this data is not known. Whether these recommendations

Conclusions

Airway obstruction is frequent in the critically ill and injured. Restoring a clear airway is an immediate priority and if this fails death is inevitable and rapid. For those skilled and practiced in its use the tracheal tube remains the best airway during resuscitation. However, alternative airway management may be required initially and in circumstances when tracheal intubation fails. There is a reasonable argument that intubation should not even be attempted by the inexperienced or

Additional Information

The British Medical Journal published a case report in November 2004, which described gastric rupture ascribed to the use of a SAD during out-of-hospital CPR.95 The article was heavily criticised for lacking evidence for any causal relationship between the choice of airway and the complication. However, the considerable electronic correspondence96 that followed is well worth reading for any reader interested in further details of this debate.

Conflict of interest

Dr. Cook has been paid to lecture by Intavent Orthofix and the LMA Company, both distributors of laryngeal masks.

Acknowledgement

Figure 6b and c are included with the permission of the LMA company.

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    A Spanish translated version of the summary of this article appears as Appendix in the online version at 10.1016/j.resuscitation.2005.10.015.

    ☆☆

    This article is based on a lecture given by Dr. Cook at Life Support 2005. It represents a personal interpretation of the literature on the subject and focuses primarily on the potential use of laryngeal masks during resuscitation. Other important supraglottic airways are discussed.

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