Backup airways: which to keep in the ALS bag?

[fiznat]

My company has had the Combitube for a while now, but recently we have also started stocking LMAs in 3 sizes (not sure of the numbers off hand, I think they are #3, #4, #5? Small, medium, large in any case).

Assuming there is only room for ONE of these backup airways in addition to your regular intubation gear in the carry-in bag, which would you choose? Combitube or one of the LMAs?

We've got those big red StatPaks that are pretty much already packed to the brim with all kinds of stuff. Assume for the purpose of this thread that there is a set amount of available room and that something else cannot be removed to make enough space to carry both. Naturally we can stock both in the truck, but room for only one in the bag.

[paramedicmike]

On the ground we use Combitubes. In the air we use LMAs. If given a choice between the two I'd go with the LMA. You just need to add a few sizes to what you carry.

We carry LMAs from 1.5 up to size 5 and all of them fit together into a relatively small box. They're easy to use and place. When placed they provide a good ventilatory adjunct. With a choice in sizes you get a wider range of use than with a combitube.

But that's just me.

-be safe

[chbare]

Every device has it's good and bad aspects. I think the key is to choose a device or devices and know learn how to use it/them effectively.

With that said, I would have to go with the LMA as well. This is due to the fact that LMA's come in sizes that cover nearly every age. Otherwise, ETC's are an effective device for the adult population.

Take care,

chbare.

[fiznat]

Why the LMA though? True it is a little easier to place and it fits a wider population of patients, but it doesn't protect the airway from aspiration at all. What about that aspect?

Also understand that we won't be able to fit the whole set of LMAs in the bag. Probably just the big one or maybe the two smaller ones.

[chbare]

In that case, you may give greater consideration to the ETC. Population dependant. However, the LMA does offer some unique advantages:

-The design will protect the glottis and lungs from aspiration of upper airway matter.

-The LMA is easy to insert.

-The LMA can be inserted with minimal spinal or head movement.

-The LMA is available in many sizes.

-The LMA comes in many different styles;

*ILMA-allows the provider to attempt ETI.

*LMA Proseal-uses a gastric tube for GI decompression. I believe it will tolerate airway pressures up to 30. This is comparable to the ETC.

*LMA flexible-flexible tube allows placement in unique surgical conditions.

*Classic LMA-is reusable and can be cleaned and autoclaved.

*Newer LMA's with fiber optic viewing technology.

Take care,

chbare.

[flightmedic46]

Quote from our clinical educator, "Intubation---failure is not an option". Nice but not always true. I think there are pro's and con's to both. In additon to those already stated LMA not as much protection from aspiration. Combitube has worse sucess rate. I have been researching the new King Airway. It seems to be easer to insert and more user friendly. Also LMA's can be bulky to fit into an already crowed response bag.

[Spock]

I've used the LMA and King airways extensively and have had to change the combitube in the trauma bay. I think the King wins hands down with the only reservation being no pediatric sizes yet. Pediatric Kings are coming as the Beta tests are underway.

That said we should remember that the PALS recommendations for prehospital pediatric airway management is to use the BVM.

I also do not agree with the failure at intubation is not an option. You should always have a backup plan for every airway management case.

Live long and prosper.

Spock

[AZCEP]

None of the available choices are going to perform very well once the airway is full of fluids inherent to poor intubation technique. The LMA doesn't have a place in the prehospital environment. It is too easy to dislodge, and does a poor job of protecting from aspiration.

The King LT is the way to go. Easy to place, simple to replace with an ET tube, no latex. The sizes that are available fit a wide range of patients, so that should not be a concern. Pediatric back up devices are a waste of money in most cases.

[tniuqs]

Just my 2 cents...American on par now !

The LMA is NOT a good airway at all in my opinion at all....ever try to secure one and then come down 3 flights of stairs. These we designed for short term usage in ORs and are superior to the mask for short term ventilation, in the OR. Thing is that the studies done on the LMA are not the field, therefore the patients were npo prior to use, for EMS most patients eat 20 pounds of sausage and potatoe chips prior to arresting...i think this is an written rule?

The piece of kit for b/u I want is a Bougie stylette.

cheers

[chbare]

I understand all of the disadvantages of the LMA; however, you cannot deny that the LMA has advantages as well. Unfortunately, the research that I have seen regarding these two devices is all over the place. I think it would be hard to conclude that one device is definitively superior to another. Both devices have advantages and disadvantages.

One has to remember why we are using these devices. We are placing these devices to rescue us from an ominous situation. We are essentially one step away from cutting flesh when we choose to insert these airways. Most would agree that both airways will function well as rescue devices.

I think it really comes down to personal preference and experience when we look at these devices. I have yet to find highly definitive evidence one way or the other. I would hate to condemn the use of the LMA based on personal preference. With that, I have seen both devices function well in the rescue airway setting.

I would agree that the King will most likely prove to be one of the best supraglottic devices available. The new King LTS has a gastric port that allows for GI decompression. I think this feature will only improve on a great design. However, my answer was based on the assumption that the person does not have access to the King and must choose between the ETC or LMA.

Take care,

chbare.