Review ArticleNew airways for resuscitation?☆,☆☆
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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Cited by (70)
Visual recognition of anatomical structures in a circulated and in a non-circulated airway
2016, American Journal of Emergency MedicineSupreme Laryngeal Mask Airway achieves faster insertion times than Classic LMA during chest compressions in manikins
2014, American Journal of Emergency MedicineCitation Excerpt :The participants found SLMA easier to use in both scenarios (CPR: SLMA 8.8 ± 1.4, CLMA 7.6 ± 1.9, P < .001; non-CPR: SLMA 9.1 ± 1.4, CLMA 8.0 ± 1.7, P < .001) and felt more confident using SLMA (SLMA: 9.0 ± 1.2, CLMA: 7.8 ± 1.8, P < .001) and 94% of them would prefer SLMA for future use. The use of SADs during CPR appears to have gained popularity compared to ETI [4,5], which is often associated with serious complications [19-24]. To the best of our knowledge the present study is the first one to compare directly the insertion parameters of SLMA and CLMA in a CPR model.
Non–Laryngeal Mask Airway Supraglottic Airway Devices
2013, Benumof and Hagberg's Airway ManagementNon-Laryngeal Mask Airway Supraglottic Airway Devices
2012, Benumof and Hagberg's Airway Management: Third EditionCadaver study of oesophageal insufflation with supraglottic airway devices during positive pressure ventilation in an obstructed airway
2012, British Journal of AnaesthesiaCardiac arrest in special populations
2012, Emergency Medicine Clinics of North AmericaCitation Excerpt :Video or optical laryngoscopic modalities have shown promise for successful airway management with decreased times for tube placement and minimizing cervical spine manipulation.1,5–7 Supraglottic blind insertion airway devices (King LT [King Systems, Noblesville, IN, USA] LMA [LMA North America, Inc, San Diego, CA, USA], and others) may also be useful in difficult airway or failed intubation.8 These devices may also be in place as part of prehospital resuscitation efforts.
- ☆
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.