Endotracheal Tube or Combitube??

[Ace844]

"VCFD,"

We have recently had alot of discussion about this, you can find your info in both the entubation/RSI and other airway threads here as well as in the 2 links posted below. As far as some more specific info to the LMA here's a start cross posted from another thread..

The reason I have this belief is partailly due to what you have stated. A Combi-Tube isn't necessarily a definitive primary airway, to be used in place of/due to a lack of proper positioning, lack of a definitve airway, and or, ETI There are very few circumstances where you can't "BLS" an airway with proper technique and an OPA/NPA. Especially in the setting of failed ETI. Next, If the patient can take a Combi-Tube, they should be able to be entubated. I see I also see the lack of adequate training, phys/anatomy knowledge, and a "HUGE," risk of iatrogenic trauma as was mentioned previously here. ..This is a prime example of why I don't want this provider or anyone similiarly educated shoving a mostly rigid plastic 'airway' in to the pharynx/espohagus of anyone I know, or my family... Also, I forsee the "training for combi-tube resembling that of the basic ETI training program they have on Martha's Vineyard and the islands and or the RI ETI BLS add on. Did you know that after an 8hr class and a "manikin" entubation they let basic intubate here (the islands) and there!!! That is SCARY!! I personally feel the risks are significanly less of this with an LMA. My experiences haven't been bad with the ALS providers using them as most here have only used them when testing for the state or registry, they sit unused in the cabinet collecting dust..Sad but true..

http://www.mass.gov/dph/oems/protocol/trea...t_protocols.pdf

http://www.emsinstitute.org/old/documents/combitube.pdf

http://www.anesth.umontreal.ca/3_etudes/en...trauma_2004.pdf

http://www.caep.ca/004.cjem-jcmu/004-00.cj...3.179-209iv.htm

http://www.gov.mb.ca/health/ems/protocols/etc.pdf

http://www.charlottesweb.hungerford.org/Do...lsRev092002.doc

http://www.caep.ca/004.cjem-jcmu/004-00.cj...002/v45-338.htm

http://www.mhsqa.com/english/Newletters/Qu...Winter_2002.pdf

http://www.americanheart.org/downloadable/...5Dec04Final.pdf

http://www.ccmjournal.com/pt/re/ccm/abstra...9856145!9001!-1

http://www.disaster.org.tw/ENGLISH/vol1no2/4.pdf

http://www.medradio.org/combitube/DiffAir%202-2_X.pdf

http://www.emsinstitute.org/old/bls/combitube.asp

http://www.jtrauma.com/pt/re/jtrauma/abstr...9856145!9001!-1

http://www.caep.ca/004.cjem-jcmu/004-00.cj...002/v45-338.htm

References

1. Baskett PJF. The laryngeal mask in resuscitation [editorial]. Resuscitation 1994;28:93-5.

2. Davies PRF, Tighe SQM, Greenslade GL, Evans GH. Laryngeal mask airway and tracheal tube insertion by unskilled personnel. Lancet 1990;336:977-9.

3. Lawes EG, Baskett PJF. Pulmonary aspirations during unsuccessful cardiopulmonary resuscitation. Intensive Care Medicine 1987;13:379-82.

4. The use of the laryngeal mask airway by nurses during cardiopulmonary resuscitation. Results of a multicentre trial. Anaesthesia 1994;49:3-7.

5. Reinhart DJ, Simmons G. Comparison of the placement of the laryngeal mask airway with endotracheal tube by paramedics and respiratory therapists. Ann Emerg Med s1994;24:260-3.

6. Alexander R, Hodgson P, Lomax D, Bullen C. A comparison of the laryngeal mask airway and Guedel airway, bag and facemask for manual ventilation following formal training. Anaesthesia 1993;48(3):231-4.

7. Rumball CJ, MacDonald D. The PTL, Combitube, laryngeal mask, and oral airway: a randomized prehospital comparative study of ventilatory device effectiveness and cost effectiveness in 470 cases of cardiorespiratory arrest. Prehosp Emerg Care 1997;1(1):1-10.

8. Tanigawa K, Shigematsu A. Choice of airway devices for 12,020 cases of nontraumatic cardiac arrest in Japan. Prehosp Emerg Care 1998;2:96-100.

9. Dickinson M, Curry P. Training for the use of the laryngeal mask in emergency and resuscitation situations. Resuscitation 1994;28:111-3.

10. Larmon B, Schriger DL, Snelling R, Morgan MT. Results of a 4-hour endotracheal intubation class for EMT-basics. Ann Emerg Med 1998;31(2):224-7.

11. Stratton SJ, Kane G, Gunter CS, Wheeler C, Ableson-Ward C, Reich E, et al. Prospective study of manikin-only versus manikin and human subject endotracheal intubation training of paramedics. Ann Emerg Med 1991;20:1314-8.

12. Stewart RD, Paris PM, Pelton GH, Garretson D. Effect of varied training techniques on field endotracheal intubation success rates. Ann Emerg Med 1984;13(11):1032-6.

13. Gausche MRJ, Lewis SJ, Stratton BE, Haynes CS, Gunter SM, Goodrich PD, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000;283:783-90.

As well as those below:::

Here’s an example/sample protocol for Combi-tube use, etc.. for those who may not know about it..…

APPENDIX – DUAL LUMEN AIRWAY – “COMBITUBEâ€

Introduction:

The Combitube airway is designed to provide a patent airway for arrested patients (respiratory / cardiac) when visualization of the airway or endotracheal intubation is not possible. It is designed to be inserted blindly. The double lumen design allows effective ventilations to be provided regardless of whether esophageal or tracheal placement is accomplished. The pharyngeal balloon fills the hypopharynx, eliminating the need for a mask seal, and the associated face/mask seal problems. If the Combitube is placed in the esophagus, the distal cuff will occlude the esophagus preventing aspiration of gastric content. Ventilations are then provided through the perforations at the pharyngeal site. If the device is place in the trachea, it functions as an endotracheal tube, with the distal cuff preventing aspiration.

Indications:

1. Patients in irreversible respiratory arrest. (i.e. narcotic overdose, hypoglycemia)

2. Patients in cardiac arrest.

3. Unconscious patients without a gag reflex, in need of ventilatory support and can not be intubated.

Contraindications:

1. Intact gag reflex

2. Patient height less than 48 inches.

3. Conscious patient.

4. Known esophageal disease. (cancer, verices)

5. Caustic substance ingestion. (acid, lye)

6. Allergy or sensitivity to latex

Precautions:

1. Take universal precautions (BSI), including facial protection, as expulsion of stomach content can occur in esophageal placement.

2. May be used in trauma in a neutral position. (flexion or extension need not occur to facilitate placement)

3. Defibrillation should not be delayed to place Combitube.

4. Pulse oximetry may be unreliable in low perfusion states, such as cardiac arrest.

Procedure:

1. Open the airway and suction mouth and oropharynx.

2. Perform assessment and record vital signs, level of consciousness, and oxygen saturation if available.

3. Insure there are no contraindications to this procedure.

4. Begin positive pressure ventilation with 100% oxygen and oral airway. Hyperventilate with each ventilation lasting at least 2 seconds.

5. Auscultate bilateral lung sounds to ensure air entry with BVM and rule out FBAO or pre-existing condition.

6. While patient is being hyperventilated, assemble Combitube as follows:

a. Attach the large syringe with 100cc’s of air to the BLUE cuff #1.

b. Attach the small syringe with 15cc’s of air to the WHITE cuff #2.

c. Test the device by inflating both balloons, looking for leaks.

d. Deflate all air from both cuffs, and leave syringes attached.

e. Attach fluid detector to the shorter white tube. (#2)

f. Lubricate tube tip and pharyngeal balloon with a water soluble lubricant.

7. With the head in a neutral position, grasp the mandible and tongue between the thumb and fingers. Place the Combitube into the midline of the mouth.

8. Slide the Combitube GENTLY along the palate and posterior surface of the oropharynx. Use a curving motion to guide the tube inward and downward. Advance the tube until the upper teeth or gums are between the two black rings.

9. DO NOT force the tube. If resistance is met, withdraw the tube, reposition the head and reattempt.

10. If unable to place the tube within 30 seconds, hyperventilate with 100% oxygen for 1-2 minutes before you reattempt.

11. Inflate large pharyngeal balloon (#1) with 100cc of air.

- 85ml of air for 37 French size.

12. Inflate distal balloon (#2) with 15cc of air. (DO NOT over-inflate, serious damage may result.)

- 12ml of air for 37 French size.

13. Begin ventilation through the longer blue connecting tube #1.

14. Confirm tube placement by auscultating both lungs and gastric area. If appropriate breath sounds are heard esophageal placement has occurred continue to ventilate and continuously monitor for change.

15. If no breath sounds are heard and gastric sounds are appreciated, remove fluid deflector from the white tube, attach BVM and begin ventilation through tube #2.

16. Confirm tube placement by auscultating both lungs and gastric area. If appropriate breath sounds are heard tracheal placement has occurred continue to ventilate and continuously monitor for changes.

17. If no breath sounds are heard and no gastric sounds are heard, the tube is placed to deep and occluding the tracheal opening. Deflate both balloons, and withdraw 2-3 centimeters. Re-inflate the balloons and attempt again beginning at step #13.

18. A maximum of two attempts at Combitube placement is permitted.

19. If the patient regains consciousness or gag reflex, the Combitube MUST be removed.

- Balloon Deflation Procedure:

a) Have working suction ready, and suction oropharynx.

If not contraindicated, roll patient to recovery position.

c) Deflate blue balloon #1.

d) Deflate white balloon #2.

e) Remove Combitube.

Charting and Documentation:

The following information must be charted on the patient care report form:

1. Patient’s presenting signs and symptoms, including vital signs, level of consciousness, and oxygen saturation if available.

2. Indications for Combitube use.

3. Number of endotracheal intubation attempts.

4. Size of Combitube 41 French or 37 French

5. Which connecting tube was used for ventilation. (blue or white)

6. Steps taken to verify tube placement.

7. Number of attempts made at Combitube placement.

8. Repeat assessment and vital signs every five minutes.

9. Changes from baseline that may have occurred, if any.

10. Signature and certification / license number of EMT performing insertion.

Certification:

1. Attend lecture and demonstration of Combitube placement and evaluation.

2. Demonstrate an understanding of the indications, contraindications, and possible complications related to the use of the Combitube.

3. In a lab setting, demonstrate the proper insertion, removal, and use of the Combitube.

4. Pass a written examination.

5. Pass an oral examination incorporating practical scenarios.

Continuing Certification:

1. Review class and repeat certification steps 1-5

2. Record review of all cases where this protocol has been used.

3. Recertification at the intermediate level will occur annually.

Quality Assurance:

1. The following will be measured for continuos quality improvement.

- Appropriateness of use

- Adherence to protocol

- Deviations from protocol

- Corrective action taken

2. Biannual statistics will be forwarded to each department using the Combitube.

3. Completion of a “Combitube†form, for feedback in the following areas:

- Ease of use

- Effectiveness of ventilation

- Complications of use

- Suggestions for improvement

Taylor & Francis Health Sciences, part of the Taylor & Francis Group

Volume 4, Number 4 / October–December 2000

333 - 337 Mel Ochs A1, Gary M. Vilke A1, Theodore C. Chan A1, Thomas Moats A1, Jean Buchanan A1

A1 San Diego County Department of Health Services, Division of Emergency Medical Services (MO, JB), and the Department of Emergency Medicine, University of California, San Diego Medical Center (GMV, TCC, TM), San Diego, California wrote:

SUCCESSFUL PREHOSPITAL AIRWAY MANAGEMENT BY EMT-DS USING THE COMBITUBE

Mel Ochs A1, Gary M. Vilke A1, Theodore C. Chan A1, Thomas Moats A1, Jean Buchanan A1

A1 San Diego County Department of Health Services, Division of Emergency Medical Services (MO, JB), and the Department of Emergency Medicine, University of California, San Diego Medical Center (GMV, TCC, TM), San Diego, California.

Abstract:

Objective. To evaluate the ability to train emergency medical technicians-defibrillation (EMT-Ds) to effectively use the Combitube for intubations in the prehospital environment. Methods. This was an 18-month prospective field study in which EMT-Ds were trained how and in what situations to use the Combitube. Data were then obtained for all patients in whom Combitube insertion was attempted. Indications for use of the Combitube included: unconsciousness without a purposeful response, absence of the gag reflex, apnea or respiratory rate less than 6 breaths/min, age more than 16 years, and height at least 5 feet tall. Contraindications were: obvious signs of death, intact gag reflex, inability to advance the device due to resistance, or known esophageal pathology. Data were entered prospectively from the San Diego County EMS QANet database for prehospital providers. Results. Twenty-two EMT-D provider agencies, involving approximately 500 EMT-Ds, were included as study participants. Combitube insertions were attempted in 195 prehospital patients in cardiorespiratory arrest, with appropriate indication for Combitube use. An overall successful intubation rate (defined as the ability to successfully ventilate) of 79% was observed. Identical success rates for medical and trauma patients were noted. The device was placed in the esophagus 91% of the time. Resistance during insertion was the major reason for unsuccessful Combitube intubations. An overall hospital admission rate of 19% was observed. No complications were reported. Conclusion. EMT-Ds can be trained to use the Combitube as a means of establishing an airway in the pre-hospital setting. Future studies will need to further evaluate its effect on patient outcome.

Comparison of the Esophageal-Tracheal Combitube

(ECT) and Endotracheal Tube (ETT) in the Pre-hospital Setting, Calkins TR, Langdorf MI, Miller K, Hill MA wrote:

Comparison of the Esophageal-Tracheal Combitube

(ECT) and Endotracheal Tube (ETT) in

the Pre-hospital Setting

Calkins TR, Langdorf MI, Miller K, Hill MA

Study Objectives: To compare success and complication

rates between ETC and ETTs by paramedics. Placement

with successful ventilation was the primary outcome,

with complication rates, survival to admission and discharge,

and aspiration pneumonia as secondary measures.

Methods: Retrospective review of three years of EMS

runsheets for all patients where an ECT was attempted.

Abstracters were hypothesis-blinded, trained and monitored

(Kappa =.7-1.0). This EMS system uses the ETC

primarily as an alternative airway to failed tracheal intubation.

Pharmacologically assisted intubation is not used. ETT

patients were selected from the EMS QA database for the

same period. We reviewed the charts of 19 ECT patients.

Results: ECT insertion was attempted on 200 patients:

140 (70%) successful, 55 (27.5%) failed (some for multiple

reasons), and 5 not recorded. An ETT was attempted

for 169 patients: 152 (90%) successful, 17 (10%) failed.

ECT location was noted in 104: 83 (80%) esophageal, 21

(20%) tracheal. Inability to determine placement of the

ETC was due to emesis from both ports in 28 cases and

inability to pass the ECT occurred in 29. The ECT caused

one patient dental trauma, and one ETC placement was

temporally related to the onset of subcutaneous emphysema.

Blood in the ETC from pre-existing active upper GI

bleed occurred in 10 patients (5.3%) and 6 tubes (3.2%)

dislodged. Ninety-one runsheets noted disposition; 18

(19.8%) survived to hospital admission. Of 19 ECT hospital

charts reviewed, 5 survived to admission, none to discharge.

Average admission ABGs were pH 7.02/p02 288/

pC02 57/HC03 15. Length of stay was 1-21 days, with

aspiration pneumonia present in 2/5.

Conclusions: Similar to previous reports, ETT success

was greater than ECT. In an earlier study, EMT-Ds had a

higher ECT success rate (155/195 or 79%) than paramedics

here (70%) (p=.04, OR 1.67 (95% CI 1.02-2.70).

Successful ECT use may depend on local experience and

level of specific training, rather than comprehensive paramedic

training.

Conclusions: This study suggests that a single ‘standard

of care’ is not being practiced in emergency medicine with

regards to the management of parents signing out children

An Algorithmic Approach to Prehospital Airway Management

Henry E. Wamg A1, A1, Douglas F. Kupas A1, Mark J. Greenwood A1, Mark E. Pinchalk A1, Terry Mullins A1, William Gluckman A1, Thomas A. Sweeney A1, David Hostler A1 wrote:

Prehospital Emergency Care

Publisher: Taylor & Francis Health Sciences, part of the Taylor & Francis Group

Issue: Volume 9, Number 2 / April-June 2005

Pages: 145 - 155

URL: Linking Options

DOI: 10.1080/10903120590924618

An Algorithmic Approach to Prehospital Airway Management

Henry E. Wamg A1, A1, Douglas F. Kupas A1, Mark J. Greenwood A1, Mark E. Pinchalk A1, Terry Mullins A1, William Gluckman A1, Thomas A. Sweeney A1, David Hostler A1

ENDOTRACHEAL INTUBATION AND ESOPHAGEAL TRACHEAL COMBITUBE INSERTION BY REGULAR AMBULANCE ATTENDANTS: A COMPARATIVE TRIAL

Chris Rumball A1, David Macdonald A1, Patricia Barber A1, Hubert Wong A1, Curt Smecher A1

A1 Division of Emergency Medicine, Department of Surgery (CR), University of British Columbia, Vancouver, British Columbia, Canada, and Saudi Aramco Medical Services Organization, Dhahran, Saudi Arabia; British Columbia Ambulance Service (DM, CS), Vancouver, British Columbia, Canada; Angiotech Industries (PB), Vancouver, British Columbia, Canada; and the Data & Methodology Program of Health Care and Epidemiology (HW), Canadian HIV Trials Network, University of British Columbia, Vancouver, British Columbia, Canada.

Abstract:

Objective. Recent cardiac arrest resuscitation guidelines have recommended the esophageal tracheal Combitube (ETC) as an advanced airway management alternative for individuals who infrequently perform endotracheal intubation (ETI). This study attempted to analyze basic (nonparamedic) ambulance attendant success rates at ETI and ETC insertion as well as their continuing skill competency over time and whether ongoing practice on mannequins improved skill performance. Methods. Three hundred fifty-seven adult patients in cardiorespiratory arrest were treated by 81 basic ambulance attendants. Original study design called for the analysis of two treatment options in three patient groups: ETC insertion, ETI insertion with mannequin practice (ETI-MP), and ETI insertion without mannequin practice (ETI-NMP). The main outcome measures were: (1) successful insertion and ventilation with ETC or ETI, assessed by receiving physicians; and (2) differences in successful insertion/ventilation between the MP and NMP groups. Results. Successful insertion (intent-to-treat) for the ETI-NMP group was 70 of 111 (63%; 95% confidence interval [CI], 54-73%); ETI-MP success was 105 of 139 (76%; 95% CI, 67-84%); ETC-NMP success was 26 of 42 (62%; 95% CI, 49-75%); and ETC-MP success was 36 of 53 (68%; 95% CI, 54-82%). Continuing mannequin practice appeared to improve ETI success (as-treated): MP 75% versus NMP 61% (odds ratio, 2.1; 95% CI, 1.11-3.94). Conclusions. There were similar rates of successful insertion/ventilation with the ETC and ETI. ETI insertion success was lower without mannequin practice. ETI skill erosion was partially mitigated by additional field experience.

CONCEPTS AND APPLICATION OF PREHOSPITAL VENTILATION

Marvin A. Wayne A1, Theodore R. Delbridge A1, Joseph P. Ornato A1, Robert A. Swor A1, Thomas Blackwell A1 wrote:

CONCEPTS AND APPLICATION OF PREHOSPITAL VENTILATION

Marvin A. Wayne A1, Theodore R. Delbridge A1, Joseph P. Ornato A1, Robert A. Swor A1, Thomas Blackwell A1

A1 University of Washington, Seattle, Washington (MAW); Yale University, New Haven, Connecticut (MAW); EMS, Bellingham and Whatcom County, Bellingham, Washington (MAW); Department of Emergency Medicine, University of Pittsburgh, and STAT MedEvac, Pittsburgh, Pennsylvania (TRD); Department of Emergency Medicine, Medical College of Virginia, Richmond, Virginia (JPO); EMS Programs, William Beaumont Hospital, Royal Oak, Michigan (RAS); and Mecklenburg EMS Agency and the Center for Prehospital Medicine, Carolinas Medical Center, Charlotte, North Carolina (TB).

Abstract:

Airway management and optimal ventilation are crucial aspects of managing out-of-hospital medical emergencies. The goals in these situations are controlled ventilation and optimized inspiratory time, expiratory time, and airflow. Numerous techniques and devices are available to deliver oxygen-enriched air to patients during resuscitation. The bag-valve-mask (BVM) is one of the most common devices used to provide ventilation, although the American Heart Association ranks BVM devices lower in preference than other ventilation adjuncts, such as emergency and transport ventilators (ETVs) and pocket masks. The clearly documented limitations of BVM ventilation and its widespread use in the United States underscore the need to improve ventilation practices during care provided by emergency medical services (EMS) personnel. As part of that improvement, ETVs clearly have a role in the prehospital setting. These devices should be available on every ambulance, and the ability to use ETVs should be part of each EMS provider's skill set. Furthermore, all patients requiring emergency ventilation must be adequately monitored, including continuous monitoring of end-tidal carbon dioxide concentrations. As with any other skill, ventilation requires attention during initial training, continuing education and skill reinforcement, and quality review.

FAILED PREHOSPITAL INTUBATIONS: AN ANALYSIS OF EMERGENCY DEPARTMENT COURSES AND OUTCOMES Henry E. Wang A1, Thomas A. Sweeney A1, Robert E. O'Connor A1, Howard Rubinstein A1 A1 Department of Emergency Medicine, Christiana Care Health System (HEW, TAS, REO), Newark, Delaware; the Department of Emergency Medicine, University of Pittsburgh School of Medicine (HEW), Pittsburgh, Pennsylvania; and the Department of Emergency Medicine, St. Francis Hospital (HR), Wilmington, Delaware. wrote:

FAILED PREHOSPITAL INTUBATIONS: AN ANALYSIS OF EMERGENCY DEPARTMENT COURSES AND OUTCOMES

Henry E. Wang A1, Thomas A. Sweeney A1, Robert E. O'Connor A1, Howard Rubinstein A1

A1 Department of Emergency Medicine, Christiana Care Health System (HEW, TAS, REO), Newark, Delaware; the Department of Emergency Medicine, University of Pittsburgh School of Medicine (HEW), Pittsburgh, Pennsylvania; and the Department of Emergency Medicine, St. Francis Hospital (HR), Wilmington, Delaware. Abstract:

Objective. To examine the reasons for failed prehospital endotracheal intubation (ETI) and to identify how the airway was subsequently managed in the emergency department (ED). Methods. Data were collected from January to December 1998 for a county-wide paramedic system. Failed prehospital ETIs and perceived reasons for failure were identified. Subsequent ED airway management was reviewed. Results. During the study period there were 13,112 patient contacts resulting in ETI attempts on 592 patients, of whom 536 (90.5%) were successfully intubated. Of the 56 failed field intubations, 49 (87.5%) had ED charts available for review. Endotracheal intubation failure was associated with inadequate relaxation in 24 (49%), difficult anatomy in ten (20%), and obstruction in five (10%). Successful ETI was achieved in the ED in 42 cases (86%). Twenty cases (41%) were facilitated by rapid-sequence intubation (RSI) in the ED. For those with incomplete relaxation in the field, 13 of 24 (54%) were intubated in the ED using RSI. Factors associated with the use of ED RSI include attempted prehospital nasotracheal intubation or attempted prehospital midazolam-facilitated intubation (p < 0.001). The predicted need for RSI in this prehospital system is approximately 3.9%. In eight cases, three or more ETI attempts or the use of rescue airways was required in the ED. The predicted minimum incidence of “truly difficult†intubation in this system is approximately 0.8–1.6%. Conclusions. Paramedic intubation failures result from a variety of factors. Less than half of field intubation failures were remedied in the ED by the use of neuromuscular-blocking agents. A similar number were intubated without the use of RSI. A fraction of failed field ETIs may have resulted from inadequate operator training or experience. A small percentage of field patients were “truly difficult†and required advanced resources in the ED to facilitate airway management. Medical directors should be cognizant of the numerous factors affecting intubation performance when designing and implementing approaches to difficult prehospital airways.

066 EAR: Edmonton Airway Registry.Travers AH, Panylyk P, McLelland K, Sookram S. Edmonton Emergency Response Department, City of Edmonton, Division of Emergency Medicine, University of Alberta, Edmonton, AB. wrote:

066 EAR: Edmonton Airway Registry.

Travers AH, Panylyk P, McLelland K, Sookram S. Edmonton Emergency Response Department, City of Edmonton, Division of Emergency Medicine, University of Alberta, Edmonton, AB.

INTRODUCTION: Despite previous research, the determinants of airway intubation success remain elusive and are affected by a number of interactions and confounders. A statistical construct termed a 'causal pathway' was created in this study to allow multivariate analyses of predictor variables on airway success. This causal pathway is as follows:

Medic --> Environment --> Patient --> Airway --> Medications ===> Airway Success

We propose that the individual predictors in each domain incrementally affect the next domain, ultimately affecting the outcome measure of airway intubation success. The objective of this study is to evaluate the determinants of intubation success or failure using a novel causal pathway model. METHODS: Prospective observational cohort for invasive airway management in an Emergency Medical Service (EMS) using an intubation registry completed concurrent to patient prehospital care. There are no 'Rapid Sequence Protocols' utilized in this EMS service staffed by 300 EMS personnel and 24 ambulances. RESULTS: The EAR encompasses comprehensive evaluation of invasive airway management between November 2001 and December 2002 and is ongoing. In total there were 589 cases requiring invasive airway management with 83% (488/589) being intubated with a median number of attempts of 1 (Range 1 to 4). Of the remaining 101 cases: 50 had insertion of a combitube; 17 failed combitube and required simple Bag-Valve-Mask (BVM) maneuvers till Emergency Department (ED) arrival; and 34 had BVM until ED arrival. No surgical airways performed in this cohort. Multivariate analysis with the causal pathway model is currently under data interrogation. CONCLUSION: Our endotracheal intubation (ETI) success rate of 83%, and a combitube success rate of 75% for those failing ETI. Further multivariate modeling using a causal pathway paradigm will serve to determine the key predictors for the airway success. Key words: airway management.

Next I will address the LMA comments….You can entubate and suction through an LMA, for those who don’t know about them here is some more info. And studies to read..

Evaluation of prehospital insertion of the laryngeal mask airway by primary care paramedics with only classroom mannequin training

Michael J. Murray, MD;* Marian J. Vermeulen, MHSc;† Laurie J. Morrison, MD, MSc;†‡ Tim Waite, A-EMCA§ . wrote:

Evaluation of prehospital insertion of the laryngeal mask airway by primary care paramedics with only classroom mannequin training

Michael J. Murray, MD;* Marian J. Vermeulen, MHSc;† Laurie J. Morrison, MD, MSc;†‡ Tim Waite, A-EMCA§

Waite, A-EMCA§

*Medical Director and §Program Director, Base Hospital Program, Department of Emergency Services, Royal Victoria Hospital, Barrie, Ont. †Division of Prehospital Care, Department of Emergency Services, Sunnybrook and Women's College Health Sciences Centre; Department of Health Administration, University of Toronto, Toronto, Ont. ‡Division of Emergency Medicine, Department of Medicine, University of Toronto, and Toronto Emergency Medical Services, Toronto, Ont.

Presented at the Canadian Association of Emergency Physicians Annual Scientific Meeting, Hamilton, Ont., Apr. 18-20, 2002.

Received: Nov. 19, 2001; final submission: June 5, 2002; accepted: June 15, 2002

This article has been peer reviewed.

ABSTRACT

Introduction: The laryngeal mask airway (LMAâ„¢ airway) provides adequate ventilation and offers a suitable alternative for airway management in patients with cardiac arrest if primary care paramedics do not have intubation skills or are unable to intubate. Training in the use of the LMA usually occurs in the operating room.

Objective: To describe the use of the LMA by paramedics in prehospital adult non-traumatic cardiac arrest patients after classroom mannequin training. The study took place in a suburban rural emergency medical service.

Methods: This is a 2-phase observational study of the effect of paramedic training for LMA insertion using a mannequin and the success rate in the prehospital setting. All paramedics successfully completed classroom mannequin training. All subsequent prehospital adult non-traumatic cardiac arrest patients from mid-February 1999 to Mar. 31, 2000, were eligible. Subjective assessment of chest expansion, ease of ventilation and auscultation defined adequacy of ventilation. Data collected included the number of insertion attempts, reasons for failure, ease of insertion, adverse events and reasons for not attempting intubation. Statistical analysis comprised descriptive frequencies, chi-squared tests for comparison of categorical variables and analysis of variance for continuous variables.

Results: 208 paramedics (100%) successfully completed training. The mean number of attempts was 1, and only 4 (2.1%) paramedics required a second attempt with a mannequin. The paramedics' perception of ease of use comparing the LMA with a bag valve mask (BVM) was evenly distributed across the 3 descriptors: 70 (39%) scored the LMA as easier to use, 57 (31%) as more difficult, and 54 (30%) stated there would be no difference. Of the 291 arrests during the study period, insertion of the LMA was attempted in 283 (97.3%) and was successful in 199 (70%) patients. The LMA became dislodged in 5 (2.5%) cases and was removed in 12 (6%) to clear vomit from the airway. The overall success rate was 182 (64%). The incidence of regurgitation prior to attempted insertion of the LMA was 28% (79 patients). Success rates did not vary significantly with the incidence of vomiting prior to insertion (p = 0.11). The majority of the paramedics evaluated LMA insertion as Very easy 49/220 (22.3%) or Easy 87/220 (39.6%). Paramedic evaluation of ease of use varied with success (p = 0.001).

Conclusions: This study reports a 100% training success rate with a mannequin and a 64% success with LMA insertion and ventilation in the field by paramedics among adult out-of-hospital non-traumatic cardiac arrest patients.

RÉSUMÉ

Introduction : Le Laryngeal Mask Airwaymd (LMA) (masque laryngé) offre une ventilation adéquate ainsi qu'une solution de rechange appropriée lors de la prise en charge des voies aériennes de patients en arrêt cardiaque si les ambulanciers paramédicaux de soins immédiats (APSI) ne possèdent pas les habiletés d'intubation ou sont incapables d'intuber. La formation à l'utilisation du LMA s'effectue en salle d'opération.

Objectif : Décrire l'utilisation du LMA par les APSI chez des patients adultes en arrêt cardiaque non traumatique à la suite d'une formation en classe sur des mannequins. L'étude eut lieu dans un service d'urgence en milieu rural.

Méthodes : Il s'agissait d'une étude d'observation en deux étapes sur l'effet de la formation à l'insertion du LMA sur un mannequin et le taux de succès en milieu préhospitalier. Tous les APSI complétèrent avec succès la formation en classe sur des mannequins. Tous les patients adultes victimes d'arrêts cardiaques non traumatiques subséquents reçus entre la mi-février 1999 et le 31 mars 2000, étaient admissibles à l'étude. Une évaluation subjective de l'expansion thoracique, de la facilité de la ventilation et d'auscultation constituait le critère de définition de la réussite de la ventilation. Les données recueillies comprenaient le nombre de tentatives d'insertion, les raisons de l'échec des tentatives, la facilité d'insertion, les résultats négatifs et les raisons de ne pas tenter l'intubation. L'analyse statistique était constituée des fréquences descriptives, des tests Chi2 pour comparaison des variables catégorielles et de l'analyse de variance pour les variables continues.

Résultats : Deux cent huit APSI (100 %) complétèrent la formation avec succès. Le nombre moyen de tentatives était de 1 et seulement 4 APSI (2,1 %) durent effectuer une seconde tentative sur un mannequin. La perception des APSI de la facilité d'utilisation comparativement au masque laryngé avec sac-valve-masque était répartie également entre les trois descripteurs : 70 (39 %) d'entre eux jugèrent que le LMA était le plus facile à utiliser, 57 (31 %) qu'il était le plus difficile à utiliser et 54 (30 %) ne virent aucune différence. Parmi les 291 arrêts au cours de la période d'étude, l'insertion d'un LMA fut tentée chez 283 (97,3 %) d'entre eux et réussie chez 199 patients (70 %). Le LMA se délogea dans cinq cas (2,5 %) et fut retiré dans 12 cas (6 %) pour dégager les voies aériennes des vomissements. Le taux de succès global était de 182 (64%). L'incidence de régurgitation avant la tentative d'installation du LMA était de 28 % (79 patients). Les taux de succès ne variaient pas de façon significative avec l'incidence de vomissements avant l'inertion (p = 0,11). La majorité des APSI évaluèrent l'insertion comme étant Très facile : 49/220 (22,3 %) ou Facile : 87/220 (39,6 %). L'évaluation par les APSI de la facilité d'utilisation variait selon le taux de succès (p = 0,001).

Conclusions : La présente étude indique un taux de succès de la formation de 100 % sur un mannequin et un taux de succès de 64 % avec l

Evaluation of prehospital insertion of the laryngeal mask airway by primary care paramedics with only classroom mannequin training

Michael J. Murray, MD;* Marian J. Vermeulen, MHSc;† Laurie J. Morrison, MD, MSc;†‡ Tim Waite, A-EMCA§ . wrote:

ABSTRACT

Introduction: The laryngeal mask airway (LMAâ„¢ airway) provides adequate ventilation and offers a suitable alternative for airway management in patients with cardiac arrest if primary care paramedics do not have intubation skills or are unable to intubate. Training in the use of the LMA usually occurs in the operating room.

Objective: To describe the use of the LMA by paramedics in prehospital adult non-traumatic cardiac arrest patients after classroom mannequin training. The study took place in a suburban rural emergency medical service.

Methods: This is a 2-phase observational study of the effect of paramedic training for LMA insertion using a mannequin and the success rate in the prehospital setting. All paramedics successfully completed classroom mannequin training. All subsequent prehospital adult non-traumatic cardiac arrest patients from mid-February 1999 to Mar. 31, 2000, were eligible. Subjective assessment of chest expansion, ease of ventilation and auscultation defined adequacy of ventilation. Data collected included the number of insertion attempts, reasons for failure, ease of insertion, adverse events and reasons for not attempting intubation. Statistical analysis comprised descriptive frequencies, chi-squared tests for comparison of categorical variables and analysis of variance for continuous variables.

Results: 208 paramedics (100%) successfully completed training. The mean number of attempts was 1, and only 4 (2.1%) paramedics required a second attempt with a mannequin. The paramedics' perception of ease of use comparing the LMA with a bag valve mask (BVM) was evenly distributed across the 3 descriptors: 70 (39%) scored the LMA as easier to use, 57 (31%) as more difficult, and 54 (30%) stated there would be no difference. Of the 291 arrests during the study period, insertion of the LMA was attempted in 283 (97.3%) and was successful in 199 (70%) patients. The LMA became dislodged in 5 (2.5%) cases and was removed in 12 (6%) to clear vomit from the airway. The overall success rate was 182 (64%). The incidence of regurgitation prior to attempted insertion of the LMA was 28% (79 patients). Success rates did not vary significantly with the incidence of vomiting prior to insertion (p = 0.11). The majority of the paramedics evaluated LMA insertion as Very easy 49/220 (22.3%) or Easy 87/220 (39.6%). Paramedic evaluation of ease of use varied with success (p = 0.001).

Conclusions: This study reports a 100% training success rate with a mannequin and a 64% success with LMA insertion and ventilation in the field by paramedics among adult out-of-hospital non-traumatic cardiac arrest patients.

RÉSUMÉ

Introduction : Le Laryngeal Mask Airwaymd (LMA) (masque laryngé) offre une ventilation adéquate ainsi qu'une solution de rechange appropriée lors de la prise en charge des voies aériennes de patients en arrêt cardiaque si les ambulanciers paramédicaux de soins immédiats (APSI) ne possèdent pas les habiletés d'intubation ou sont incapables d'intuber. La formation à l'utilisation du LMA s'effectue en salle d'opération.

Objectif : Décrire l'utilisation du LMA par les APSI chez des patients adultes en arrêt cardiaque non traumatique à la suite d'une formation en classe sur des mannequins. L'étude eut lieu dans un service d'urgence en milieu rural.

Méthodes : Il s'agissait d'une étude d'observation en deux étapes sur l'effet de la formation à l'insertion du LMA sur un mannequin et le taux de succès en milieu préhospitalier. Tous les APSI complétèrent avec succès la formation en classe sur des mannequins. Tous les patients adultes victimes d'arrêts cardiaques non traumatiques subséquents reçus entre la mi-février 1999 et le 31 mars 2000, étaient admissibles à l'étude. Une évaluation subjective de l'expansion thoracique, de la facilité de la ventilation et d'auscultation constituait le critère de définition de la réussite de la ventilation. Les données recueillies comprenaient le nombre de tentatives d'insertion, les raisons de l'échec des tentatives, la facilité d'insertion, les résultats négatifs et les raisons de ne pas tenter l'intubation. L'analyse statistique était constituée des fréquences descriptives, des tests Chi2 pour comparaison des variables catégorielles et de l'analyse de variance pour les variables continues.

Résultats : Deux cent huit APSI (100 %) complétèrent la formation avec succès. Le nombre moyen de tentatives était de 1 et seulement 4 APSI (2,1 %) durent effectuer une seconde tentative sur un mannequin. La perception des APSI de la facilité d'utilisation comparativement au masque laryngé avec sac-valve-masque était répartie également entre les trois descripteurs : 70 (39 %) d'entre eux jugèrent que le LMA était le plus facile à utiliser, 57 (31 %) qu'il était le plus difficile à utiliser et 54 (30 %) ne virent aucune différence. Parmi les 291 arrêts au cours de la période d'étude, l'insertion d'un LMA fut tentée chez 283 (97,3 %) d'entre eux et réussie chez 199 patients (70 %). Le LMA se délogea dans cinq cas (2,5 %) et fut retiré dans 12 cas (6 %) pour dégager les voies aériennes des vomissements. Le taux de succès global était de 182 (64%). L'incidence de régurgitation avant la tentative d'installation du LMA était de 28 % (79 patients). Les taux de succès ne variaient pas de façon significative avec l'incidence de vomissements avant l'inertion (p = 0,11). La majorité des APSI évaluèrent l'insertion comme étant Très facile : 49/220 (22,3 %) ou Facile : 87/220 (39,6 %). L'évaluation par les APSI de la facilité d'utilisation variait selon le taux de succès (p = 0,001).

Conclusions : La présente étude indique un taux de succès de la formation de 100 % sur un mannequin et un taux de succès de 64 % avec l'insertion du LMA et la ventilation sur les lieux de l'incident par des APSI chez des patients adultes victimes d'arrêts cardiaques non traumatiques en situation préhospitalière.

Key words: emergency medical services, airway, education, cardiac arrest

Introduction | Methods | Results | Discussion | Conclusions | References

Introduction

The laryngeal mask airway (LMAâ„¢ airway; LMA North America, San Diego, Calif.) was invented in 1981 by AIJ Brain, an anesthetist, was introduced commercially to some European markets in 1988 and approved for use in the United States in the early 1990s. It is estimated that it has been used on over 15 million patients.1 Endotracheal (ET) intubation is the gold standard for airway management and ventilation in cardiac arrest.2,3 The LMA offers a satisfactory alternative for airway management in cardiac arrest for prehospital providers lacking advanced airway training.2,4-8

The LMA is a soft rubber shaft of 5.25 to 12 mm diameter connected to an inflatable elliptical shaped device that resembles a small version of a facemask. This elliptical end of the device, when properly inserted, sits in the laryngeal inlet up against the esophageal sphincter. The epiglottis is usually free floating within the mask and does not obstruct air flow. When inflated, the mask fills the pyriform fossa on either side and abuts the tongue, pushing the tongue forward. The LMA has been demonstrated to provide adequate ventilation, it requires little time for insertion and runs a low risk of regurgitation.4-8

Prehospital provider performance subsequent to various training methods for LMA insertion has not been prospectively evaluated. Training options include didactic, mannequin and practical application in the operating room (OR). Operating room time is a premium resource, with paramedic training competing with other medical teaching programs for exposure to controlled airway education in live subjects. Time required for adequate OR exposure to achieve competence may be prolonged, increasing the cost of initial certification and maintenance of competence programs. Mannequin training provides greater flexibility of training and recertification at a much lower cost.

This observational study was designed to describe the use of the LMA in prehospital adult non-traumatic cardiac arrest patients by primary care paramedics (PCPs) following classroom mannequin training. Specifically, we set out to examine intubation success rate, frequency of attempt, as well as the comfort level of the paramedic (in the classroom and in the field) and the receiving physician with the device.

Methods

Setting

The study took place in a suburban rural emergency medical services (EMS) system (75 000 emergency calls per year) that serves 8 community emergency departments (EDs). At the time of the study, 209 paramedics were trained to the level of a primary care paramedic (PCP or EMT-D), and it is the paramedics with this level of training that we refer to in this study. In addition to semi-automatic defibrillation, PCPs are able to administer subcutaneous nitroglycerin, nebulized ventolin, subcutaneous epinephrine, sublingual nitroglycerin and intramuscular glucagon.

Design

This was an observational study conducted in 2 phases. Phase one involved the training of paramedics in the use of the LMA using mannequins and the evaluation of paramedic ease of use when compared to bag valve mask (BVM). Phase two was set up to describe the in-field success, complication rate and user evaluation of the device.

Training evaluation phase

Pre-course preparation comprised a 2-hour self-preparation module and training video followed by 4 hours of didactic teaching and classroom practice on an ALS Trainerâ„¢ mannequin (Laerdal Medical Corporation, Wappingers Falls, NY; www.laerdal.com). Routine recertification of paramedics began in mid-September 1999 and concluded in mid-November 1999, 9 months after the initiation of the study.

Field evaluation phase

All adult non-traumatic cardiac arrest patients who were treated in the field and then transported to hospital by paramedics from mid-February 1999 to Mar. 31, 2000, were eligible for inclusion in the study. Paramedics responding to a cardiac arrest call initiated the protocols for cardiac arrest management. The second crew member inserted the LMA during the first minute of cardiopulmonary resuscitation if initial shock analysis and defibrillation were unsuccessful. The paramedics reverted to an oral airway and BVM if at any time complications were encountered with ventilation. On arrival of the patient at the ED, the receiving physician assessed the adequacy of ventilation and either continued ventilation with the LMA or replaced it with an ET tube.

Outcome measures

In phase one, a paramedic's success with LMA insertion was defined as correct LMA placement on 2 occasions and a passing mark (>80%) by the paramedic on the written examination. The time to correct insertion of the LMA in the mannequin was recorded. The paramedics scored their comfort with use of the device on a 5-point Likert scale from "Very easy" to "Very difficult," with "Neither" as the mid-point of the scale.

In phase two, successful LMA insertion was defined by adequate ventilation and confirmation of placement. The adequacy of ventilation was determined by the paramedic at the scene and by the emergency physician or respiratory therapist on arrival in the ED. Subjective assessment of chest expansion, ease of ventilation and auscultation defined adequacy of ventilation. The number of insertion attempts, reasons for failure, ease of insertion, adverse events and reasons for not attempting intubation were recorded. The emergency physicians were surveyed using a nonvalidated instrument. They scored the ease of ventilation and acceptability of the insertion of the LMA based on a 3-point Likert scale (i.e., Acceptable, Not acceptable and Very acceptable).

Analysis

Data were captured on the ambulance call report, and the evaluation form was completed after each LMA use. The data were abstracted by an EMS data entry clerk and entered into a Microsoft Access database. Descriptive statistics (frequencies and means) were calculated for the number of insertion attempts and success rates. Statistical analysis comprised chi-squared analysis for comparison of categorical variables. Analysis of variance was used to compare success rates according to the number of opportunities for attempted LMA insertion among individual paramedics. To determine whether success rates changed following recertification, the time period from mid-February to recertification was compared with the period that followed recertification, through to the conclusion of the study on Mar. 31, 2000.

The Emergency Health Services Branch of the Ministry of Health and Long Term Care and the Medical Advisory Committee of the Provincial Base Hospital Advisory Group approved the study.

Results

Training evaluation phase

Two hundred and eight paramedics successfully completed training. Of the 193 paramedics in which number of attempts and time to insertion was recorded, the mean number of attempts was 1, and only 4 (2.1%) paramedics required a second attempt. The mean time to insertion was 19.1 seconds (standard deviation [sD], 5.7 seconds) with a range of 8 to 40 seconds. In the evaluation, 70 (39%) paramedics believed the LMA would be easier to use than an oral airway and BVM, 57 (31%) felt it would be more difficult and 54 (30%) stated there would be no difference.

Field evaluation phase

A total of 291 non-traumatic cardiac arrests occurred during the study period. Insertion of the LMA was attempted in 283 (97.3%) of these cases. Among the 8 (2.7%) remaining patients, reasons for not attempting insertion were provided for 5 patients. Two patients achieved a return of spontaneous circulation after initial defibrillation. In a third, paramedics were unable to open the patient's jaw for insertion. A decision was made to use an oral airway and BVM for another patient who became VSA (vital signs absent) during transport. There was also one instance in which the paramedic was unable to inflate the LMA during preparation of the device.

Paramedics were able to insert the LMA after one or more attempts in 199 (70%) patients. The LMA became dislodged in 5 (2.5%) cases, and 12 patients (6.0%) required its removal due to inability to clear vomit in the airway. The number of successful insertions as defined by the outcome criteria was 182 (64.3%; 95% confidence interval: 58.4%, 69.9%) (Fig. 1).

Fig. 1. Insertion of laryngeal mask airway (LMA) among patients with cardiac arrest

Among the 283 attempted insertions, the number of attempts ranged from 1 to 3 and the mean was 1.45 (SD = 0.61). The distribution of number of attempts, success rate at each attempt and cumulative success rates are shown in Table 1. The success rate did not change following recertification (before: 128/199 [64.3%]; after: 54/84 [64.3%]).

Table 1. Number of laryngeal mask airway insertion attempts and successes

Attempts Insertion attempted,

no. (and %) Insertion successful,

no. (and %) Cumulative % of total

1st 173 (61.1) 144 (83.2) 50.9

2nd 93 (32.9) 34 (34.0) 62.9

3rd 17 (6.0) 4 (23.5) 64.3

Total 283 (100.0) 182 (64.3) 64.3

Data on paramedic identification number were available for 281 cases. The number of opportunities for LMA insertion among individual paramedics ranged from 1 to 6 (Table 2). The majority of paramedics had 1 (165 [59%]) or 2 (66 [25%]) patient encounters to attempt LMA insertion. The frequency of success did not vary according to experience with insertion of the LMA (p = 0.76). The incidence of regurgitation prior to attempted insertion of the LMA was 28% (79 patients). Success rates did not vary significantly with the incidence of vomiting prior to insertion (p = 0.11).

Table 2. Number of LMA insertion attempt experiences and successes

No. of experiences Attempts,

no. (and %) Successes,

no. (and %)

1 165 (58.7) 101 (61.2)

2 66 (23.5) 47 (71.2)

3 28 (10.0) 18 (64.3)

4 15 (5.3) 10 (66.7)

5 6 (2.1) 4 (66.7)

6 1 (0.4) 1 (100.00)

Total* 281 (100.0) 181 (64.4)

* Paramedic identification number not available for 2 cases.

For the 283 attempted insertions, 220 (78%) questionnaires were completed. Table 3 shows paramedic assessment of the ease of LMA use, which varied according to whether insertion was successful (p = 0.001). Paramedics were more likely to rate insertion as Easy or Very easy among successful insertions (118 [65%]) than in those that were unsuccessful (18 [46%]).

Table 3. Paramedic evaluation of ease of insertion

Evaluation Insertion successful,

no. (and %) Insertion unsuccessful,

no. (and %) Total

Very easy 47 (26.0) 2 (5.1) 49 (22.3)

Easy 71 (39.2) 16 (41.0) 87 (39.6)

Neither 31 (17.1) 6 (15.4) 37 (16.

Difficult 14 (7.7) 11 (28.2) 25 (11.4)

Very difficult 18 (9.9) 4 (10.3) 22 (10.0)

Total* 181 (100.0) 39 (100.0) 220 (100.0)

* Paramedic evaluation not completed in 63 cases.

Questionnaires were distributed to the attending emergency physicians only for the cases in which ventilation by the paramedic had been successful (i.e., 182 cases). Of the 182 questionnaires distributed to these physicians, 126 were completed. Ventilation was rated on a 5-point Likert scale as Easy or Very easy in 94 (75%) cases and Difficult or Very difficult in 12 (9.5%) cases. The acceptability of the LMA for prehospital airway management in cardiac arrest was described using a 3-point Likert scale; 78 (62%) were rated as Very acceptable, 35 (28%) as Acceptable and 13 (10%) as Unacceptable.

Discussion

This study described a high classroom success rate for paramedics in LMA insertion training using mannequins that translated to a moderate success rate in the field and reasonable acceptability and adequacy of ventilation when judged by the paramedics and emergency physicians. If LMA insertion was to be successful only a single attempt was usually required. Regurgitation prior to attempting insertion occurred in a substantial number of patients but did not preclude success. LMA removal due to loss of correct placement or inability to clear the airway occurred in 8.5% of cases.

This study was designed to assess the success rate of LMA insertion by paramedics in prehospital non-traumatic cardiac arrest adult patients after classroom mannequin training. The training program provided the paramedics with sufficient information and opportunity to achieve 100% success rate of rapid LMA insertion in mannequins. The success rate in this study was comparable to that observed in 2 other studies.9,10 LMA field success rates were unchanged after recertification.

The success rate in the field was lower than in other prehospital studies.7,8 One retrospective review reported a successful insertion and ventilation rate of 71.5%.8 The majority of paramedics in that study received mannequin training; less than one-third received OR training. Another study compared LMA insertion with Combitube® (Kendall Company, Tyco Healthcare, Mansfield, Mass.) and the Pharyngeal-tracheal Lumen (PtL®) Airway (Gettig Pharmaceutical Instrument Company, Spring Mills, Pa.) among paramedics and respiratory therapists trained on mannequins or in the OR. The success rates for insertions were 86% with the Combitube, 82% using the PtL, and 73% using the LMA. There were no significant differences in ventilatory effectiveness with respect to arterial blood gas and spirometry in the ED. There was a trend toward a higher success rate in the group with OR training (80%) compared with those who had mannequin training (69%).8 Other studies of ET intubation and Combitube indicate that success is greater with OR practise.11,12 A study by Alexander and colleagues demonstrated that nonphysician emergency personnel were better able to ventilate with the LMA than with an oral airway and face mask (87% vs. 43%) in the OR, with no significant difference in the average insertion time.6

In our study, paramedics achieved field LMA intubation with an average of 1.45 attempts. A prospective study comparing the LMA with ET tube placement by experienced paramedics and respiratory therapists observed an average of 1 attempt for LMA insertion and 2.2 for the ET tube.5 A multicentre study that evaluated LMA insertion by nurses during cardiopulmonary resuscitation reported a 71% success rate on the first attempt and 26% on the second.4

During phase one, paramedics felt the ease of use of the LMA compared with the BVM. In phase two, the majority of paramedics described LMA use as Easy or Very easy. Not surprisingly, paramedics who had unsuccessful insertions found the device more difficult to use. The literature suggests significant ease of use on anesthetized patients with the LMA compared to the ET tube insertion.5 Paramedics rated ease of LMA insertion lower than for BVM, Combitube or PtL Airway.7

A limited sample of physicians completed the evaluation of LMA use. In most cases, the physicians rated the LMA as Easy or Very easy to use and considered it a Very acceptable method of ventilation.

Limitations

This study was observational. In addition, the outcome measures were not validated. Adequacy of ventilation was subjectively evaluated by the receiving physicians, and there was no attempt to standardize this measure. Incomplete data among both paramedics and physicians also limited the analysis. As a result, we had insufficient information to report adverse events such as regurgitation and time to insertion in the field. This study did not follow survival outcomes nor compare the LMA to other airway adjuncts, as recently reported with pediatric cardiac arrest.13

Conclusions

This study found a 64% success with LMA insertion and ventilation in prehospital adult non-traumatic cardiac arrest patients attended by paramedics who had been trained using a mannequin model. Paramedics reported ease of LMA use in 61.9% of cases in the field. More favourable support for ease of LMA use was observed in cases when insertion was successful. Regurgitation prior to attempting LMA insertion was reported in 28% of cases. Further research should prospectively evaluate LMA training and compare OR training with classroom mannequin training using standardized outcomes for field verification. There is need for a study comparing training models using objective endpoints such as tube placement confirmation, survival, adverse event rates and ease of use for LMA insertion with other airway adjuncts, including BVM and oral airway.

Competing interests: None declared.

Acknowledgements: We thank the paramedics of the region of Simcoe County and Muskoka, Ont., and Lynne Fell RVH Base Hospital, who provided administrative support.

The Emergency Health Services Branch of the Ontario Ministry of Health and Long Term Care funded the study.

BLIND TRACHEAL INTUBATION BY PARAMEDICS THROUGH THE LMA-UNIQUE David R. Barnes A1, David B. Reed A1, Gail Weinstein A1, Lawrence H. Brown A1 A1 Department of Emergency Medicine, Upstate Medical University, Syracuse, New York.. wrote:

Prehospital Emergency Care

Publisher: Taylor & Francis Health Sciences, part of the Taylor & Francis Group

Issue: Volume 7, Number 4 / October-December 2003

Pages: 470 - 473

URL: Linking Options

DOI: 10.1090/312703002235

BLIND TRACHEAL INTUBATION BY PARAMEDICS THROUGH THE LMA-UNIQUE

David R. Barnes A1, David B. Reed A1, Gail Weinstein A1, Lawrence H. Brown A1

A1 Department of Emergency Medicine, Upstate Medical University, Syracuse, New York.

Abstract:

Objective. The manufacturer of the laryngeal mask airway (LMA) reports success rates of 30-93% by practitioners attempting tracheal intubation through the LMA-Classic. No prior studies describe success rates through the (disposable) LMA-Unique by paramedics. The objective of this study was to measure the success rate of paramedics attempting to intubate the trachea blindly through the LMA-Unique. Methods. During a paramedic refresher class and an emergency medical services teaching day conference, paramedics previously trained in the use of the LMA-Unique as a "rescue" airway device were instructed in the technique of tracheal intubation through the LMA-Unique. A Laerdal LMA-mannequin was immobilized with an extrication collar and held by an investigator in the head-neutral position. Paramedics were first asked to insert the LMA-Unique as previously trained, and to confirm adequate ventilation by seeing inflation of the mannequin's lungs. Then, subjects were asked to pass a well-lubricated 6-0 Mallinckrodt endotracheal tube through the LMA-Unique within a 60-second period. Tracheal placement of the endotracheal tube was then confirmed by visualization of the expanding mannequin lungs. Rates of success of LMA-Unique placement and endotracheal tube placement were measured. Results. Fifty of the 52 (96%; CI 91% to 100%) paramedics successfully inserted the LMA-Unique on the first attempt. Only 11 of the 52 (21%; CI 10% to 32%) paramedics were successful in blind placement of the endotracheal tube into the trachea through the LMA-Unique within a 60-second period. The failures (41 of the 52) were visually confirmed to be located in the esophagus. Conclusion. In this study, when attempting blind tracheal intubation through the LMA-Unique, paramedics were rarely successful in tracheal placement. Basic LMA-Unique insertion, however, had a very high success rate.

THE LARYNGEAL TUBE: A NEW ADJUNCT FOR AIRWAY MANAGEMENT Harald V. Genzwuerker A1, Tatjana Hilker A1, Ernst Hohner A1, Baerbel Kuhnert-Frey A1 A1 Department of Anesthesiology and Intensive Care Medicine, KKH Sinsheim, Germany (HVG, BKF); and the Department of Anesthesiology and Intensive Care Medicine, KKH Schwetzingen, Germany (TH, EH).. wrote:

Prehospital Emergency Care

Publisher: Taylor & Francis Health Sciences, part of the Taylor & Francis Group

Issue: Volume 4, Number 2 / April-June 2000

Pages: 168 - 172

URL: Linking Options

DOI: 10.1080/10903120090941452

THE LARYNGEAL TUBE: A NEW ADJUNCT FOR AIRWAY MANAGEMENT

Harald V. Genzwuerker A1, Tatjana Hilker A1, Ernst Hohner A1, Baerbel Kuhnert-Frey A1

A1 Department of Anesthesiology and Intensive Care Medicine, KKH Sinsheim, Germany (HVG, BKF); and the Department of Anesthesiology and Intensive Care Medicine, KKH Schwetzingen, Germany (TH, EH).

Abstract:

Introduction. A prototype of the laryngeal tube was tested for simple and reliable use for ventilation in a mannequin. One possible use of this tube will be the management of the difficult airway. In spite of blind insertion, an inadvertent tracheal positioning should not occur due to the form of the tube. A pharyngeal cuff provides a proximal seal of the airway, while an esophageal cuff seals the airway distally and prevents aspiration of gastric contents. A ventral opening between both cuffs is used for ventilation. Objective. To examine the reliability of the laryngeal tube for airway management in a mannequin. Methods. Fifty physicians and nurses were included in this study and inserted the laryngeal tube blindly during ten consecutive attempts in an advanced life support mannequin. All participants used the laryngeal tube for the first time. Results. During 500 insertions of the tube, correct placement and sufficient ventilation were achieved 478 times in the first attempt (95.6%); 18 times (3.6%), inflating the proximal balloon with an additional 50 mL of air led to sufficient ventilation. In four attempts (0.8%), sufficient ventilation was still not possible due to the tube's not being placed deep enough (according to the printed ring marks on the tube). In each case, the tube was placed correctly in the following attempt. Neither a tracheal intubation nor ventilation of the stomach could be observed. The average time for positioning the laryngeal tube was 27.15 seconds for all 500 attempts (average time of the 50 participants for the tenth attempt: 23.85 seconds). Conclusion. The laryngeal tube may be a fast, reliable, and easy device for airway management. Further research is necessary.

www.emtcity.com/phpBB2/viewtopic.php?t=2893 &

http://www.emtcity.com/phpBB2/viewtopic.php?t=2888

Hope this helps,

ACE844

[Dustdevil]

By the way, minus 5 for starting an ALS thread in the BLS forum.

[EMS49393]

Laryngoscopy is a skill. Placing an ET tube with a laryngoscope is a skill. "Hit or missing" while attempting to place an ET tube should constitute some remedial education and OR time. Combitubes serve one purpose in my service... FAILED airway device.

You can't drop drugs down a combitube. You can truly prevent aspiration of stomach contents. Too many providers believe you just "shove" it in, which can cause damage to tissues within the airway. Combitube should not be a basic skill, mostly for that very reason. It is my opinion, and mine alone that the combitube is a product of the devil.

[Geordon]

By the way, minus 5 for starting an ALS thread in the BLS forum.

I think that you mean "YMMV" here. In EMS Region 1 of Illinois, USA, Combi-tube is a BLS skill. Therefore, your assertion that this is an ALS topic is a matter of opinion.

[DwayneEMTP]

By the way, minus 5 for starting an ALS thread in the BLS forum.

Carry the one...minus five.....wait....how many points did we start with again....?

[Dustdevil]

I think that you mean "YMMV" here. In EMS Region 1 of Illinois, USA, Combi-tube is a BLS skill. Therefore, your assertion that this is an ALS topic is a matter of opinion.

Incorrect. It is an ALS skill being performed by basics. If basics perform IV therapy or drug therapy, it does not make those interventions basic.

[safetyparamedic]

I don't think that Medicare defines a combitube as an ALS intervention, but it is called an "Advanced Airway."

[Ace844]

I don't think that Medicare defines a combitube as an ALS intervention, but it is called an "Advanced Airway."

And ALS= Advanced Life Support, so it is indeed as you so aptly put an Advanced Airway, to be performed by an ADVANCED PROVIDER....

OUT HERE,

ACE844

[medik8]

Combitube does not offer a direct pathway to the pulmonary system.

Combitube is available in limited sizes.

Combitubes do not seal the trachea at all, so they do not protect the airway as an ET does.

Combitube utilizes high pressure cuffs which cause damage to the pharynx, esophagus, and trachea.

High pressure cuffs offer inferiour seal.

Inferiour seal creates air leaks and inadequate ventilation, as well as aspiration danger.

Blind insertion creates high risk of trauma on insertion and inflation.

Blind insertion increases risk of inappropriate placement.

In appropriate placement causes death.

[BlueLifeSaver]

Combitube does not offer a direct pathway to the pulmonary system.

Combitube is available in limited sizes.

Combitubes do not seal the trachea at all, so they do not protect the airway as an ET does.

Combitube utilizes high pressure cuffs which cause damage to the pharynx, esophagus, and trachea.

High pressure cuffs offer inferiour seal.

Inferiour seal creates air leaks and inadequate ventilation, as well as aspiration danger.

Blind insertion creates high risk of trauma on insertion and inflation.

Blind insertion increases risk of inappropriate placement.

In appropriate placement causes death.

Combitubes have no place in the hands of anyone under the education level of a paramedic.

Combitubes have no place in the hands of anyone under the education level of a paramedic? Are you kidding me? I'm not sure how you guys do things where you're from, but it sounds like you're allowing a "Para-God" complex to take over your thoughts! A combitube is FAR better thans simple BVM ventilations. When placed and inflated correctly (not the full cc amount, but until resistance is felt) the combitube DOES prevent aspiration and DOES protect the patient's airway. In "my neck of the woods", EMT-Intermediates are allowed to intubate with an ET tube... only EMT-Bs can use combitubes. Endotracheal intubation in an artform, definitely, but so it the placement of a combitube. If you were the Code Blue patient, would you rather be "worked on" with a simple BVM, or a combitube that was properly placed with skilled hands. Tough choice...