Morning Report: 8/20/2013

Thanks to Dr. Alsup for today’s Morning Report!

Laryngeal Mask airway for Prehospital Respiratory Failure

LMA as a rescue airway

• It’s great when stuff hits the fan.  A certain percentage of people you just won’t be able to intubate.
  • It’s easy to fit in, it’s quick.  Minimal interruptions in CPR.
  • There are models you can pass a standard ET tube through
    • “intubating LMA”
    • Part of the supraglotic airway group
      • King LT
      • Combitube

Case for

• Interruptions in CPR are bad and lead to worse outcomes (1)
• It can work quickly in situations when the patient is in difficult position (2)
• Studies showing even with lots of training, you can intubate only 92.5% of patients with an ET tube, and the other 7.5% you can still secure an airway with an LMA (3)
• Life flight Maine 11/1998-12/2006, 5,417 flights, 369 intubation attempts
• If you can’t get ETI, especially in facial trauma, it can be a good option (4)

Case against (Resuscitation Volume 83, Issue 3, March 2012 (two studies)

• Found LMA associated with worsened survival to discharge
• 1 study with severity score matched cases, 1 cross sectional
• Who gets a LMA?
  • People with difficult airways
  • Facial trauma
  • People who you can’t ETI
  • All these cases generally take longer to intubate, or are sicker patients with worse outcomes anyway

References:

1. Bobrow BJ, Clark LL, Ewy GA, et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA 2008;299:1158–65.
2. Hoyle, John D, Jr;Jones, Jeffrey S;Deibel, Matthew;Lock, David T;Reischman, Diann. COMPARATIVE STUDY OF AIRWAY MANAGEMENT TECHNIQUES WITH RESTRICTED ACCESS TO PATIENT Prehospital Emergency Care; Jul-Sep 2007; 11, 3; ProQuest Central pg. 330
3. A. Timmermann1 *, S. G. Russo1, W. H. Rosenblatt2, C. Eich1, J. Barwing1, M. Roessler1 and B. M. Graf.  Intubating laryngeal mask airway for difficult out-of-hospital airway management: a prospective evaluation British Journal of Anaesthesia 99 (2): 286–91 (2007)doi:10.1093/bja/aem136 Advance Access publication June 21, 2007
4. Germann, Carl A, MD;Baumann, Michael R, MD;Kendall, Kevin M, MD;Strout, Tania D, RN, BSN, MS;et al Prehospital Emergency Care; Jan-Mar 2009 PERFORMANCE OF ENDOTRACHEAL INTUBATION AND RESCUE TECHNIQUES BY; 13, 1; pg. 44
5. Henry E. Wanga,∗, Daniel Szydlob, John A. Stoufferc, Steve Lind,e, Jestin N. Carlsonf, Christian Vaillancourtg, Gena Searsb, Richard P. Verbeeke, Raymond Fowlerh, Ahamed H. Idris h, Karl Koenigi, James Christensonj, Anushirvan Minokadehk, Joseph Brandtl, Thomas Ream,n , The ROC Investigators Endotracheal intubation versus supraglottic airway insertion in out-of-hospital cardiac arrest. Endotracheal intubation versus supraglottic airway insertion in out-of-hospital cardiac arrest Resuscitation 83 (2012) 1061– 1066
6. S.D. Shin et al. Out-of-hospital airway management and cardiac arrest outcomes: A propensity score matched analysis Resuscitation 83 (2012) 313– 319 

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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