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Jarvis JL, Panchal AR, Lyng JW, Bosson N, Donofrio-Odmann JJ, Braude DA, Browne LR, Arinder M, Bolleter S, Gross T, Levy M, Lindbeck G, Maloney LM, Mattera CJ, Wang CT, Crowe RP, Gage CB, Lang ES, Sholl JM. Evidence-Based Guideline for Prehospital Airway Management. PREHOSP EMERG CARE 2023; 28:545-557. [PMID: 38133523 DOI: 10.1080/10903127.2023.2281363] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 11/05/2023] [Indexed: 12/23/2023]
Abstract
Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.
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Affiliation(s)
- Jeffrey L Jarvis
- Office of the Medical Director, Metropolitan Area EMS Authority, Fort Worth, Texas
| | - Ashish R Panchal
- National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - John W Lyng
- Emergency Medicine, North Memorial Health Hospital Level 1 trauma center, Minneapolis, Minnesota
| | - Nichole Bosson
- EMS, Los Angeles County Department of Health Services, Los Angeles, California
| | | | - Darren A Braude
- Department of Emergency Medicine, The University of New Mexico, Albuquerque, New Mexico
| | - Lorin R Browne
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Arinder
- EMS, Global Medical Response Inc., Greenwood Village, Colorado
| | - Scott Bolleter
- EMS, Healthcare Innovation & Sciences Centre, Spring Branch, Texas
| | - Toni Gross
- Department of Emergency Medicine, LCMC Health, New Orleans, Louisiana
| | | | - George Lindbeck
- National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - Lauren M Maloney
- Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, New York
| | | | - Cheng-Teng Wang
- Department of Emergency Medicine, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | | | - Christopher B Gage
- Research, National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - Eddy S Lang
- Department of Emergency Medicine, Alberta Health Services, Edmonton, Canada
| | - J Matthew Sholl
- National Registry of Emergency Medical Technicians, Columbus, Ohio
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Carney N, Totten AM, Cheney T, Jungbauer R, Neth MR, Weeks C, Davis-O'Reilly C, Fu R, Yu Y, Chou R, Daya M. Prehospital Airway Management: A Systematic Review. PREHOSP EMERG CARE 2022; 26:716-727. [PMID: 34115570 DOI: 10.1080/10903127.2021.1940400] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/31/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022]
Abstract
Objective: To assess comparative benefits and harms across three airway management approaches (bag valve mask [BVM], supraglottic airway [SGA], and endotracheal intubation [ETI]) used by prehospital emergency medical services (EMS) to treat patients with trauma, cardiac arrest, or medical emergencies, and how they differ based on techniques and devices, EMS personnel and patient characteristics. Data sources: We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020. Review methods: We followed Agency for Healthcare Research and Quality Effective Health Care Program Methods guidance. Outcomes included mortality, neurological function, return of spontaneous circulation (ROSC), and successful advanced airway insertion. Meta-analyses using profile-likelihood random effects models were conducted, with analyses stratified by study design, emergency type, and age. Results: We included 99 studies involving 630,397 patients. We found few differences in primary outcomes across airway management approaches. For survival, there was no difference for BVM versus ETI or SGA in adult and pediatric patients with cardiac arrest or trauma. For neurological function, there was no difference for BVM versus ETI and SGA versus ETI in pediatric patients with cardiac arrest. There was no difference in BVM versus ETI in adults with cardiac arrest, but improved neurological function with BVM or ETI versus SGA. There was no difference in ROSC for patients with cardiac arrest for BVM versus ETI or SGA in adults and pediatrics, or SGA versus ETI in pediatrics. There was higher frequency of ROSC in adults with SGA versus ETI. For successful advanced airway insertion, there was higher first-pass success with SGA versus ETI for all patients except adult medical patients (no difference), and no difference in overall success using SGA versus ETI in adults. Conclusions: The currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion. Strength of evidence was low or moderate; most included studies were observational. This supports the need for high-quality randomized controlled trials to advance clinical practice and EMS education and policy, and improve patient-centered outcomes.
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Tang Y, Sun M, Zhu A. Outcome of cardiopulmonary resuscitation with different ventilation modes in adults: A meta-analysis. Am J Emerg Med 2022; 57:60-69. [DOI: 10.1016/j.ajem.2022.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 04/17/2022] [Accepted: 04/20/2022] [Indexed: 10/18/2022] Open
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Dorsett M, Panchal AR, Stephens C, Farcas A, Leggio W, Galton C, Tripp R, Grawey T. Prehospital Airway Management Training and Education: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:3-13. [PMID: 35001822 DOI: 10.1080/10903127.2021.1977877] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AbstractAirway management competency extends beyond technical skills to encompass a comprehensive approach to optimize patient outcomes. Initial and continuing education for airway management must therefore extend beyond a narrow focus on psychomotor skills and task completion to include appreciation of underlying pathophysiology, clinical judgment, and higher-order decision making. NAEMSP recommends:Active engagement in deliberate practice should be the guiding approach for developing and maintaining competence in airway management.EMS learners and clinicians must be educated in an escalating approach to airway management, where basic airway maneuvers form the central focus.Educational activities should extend beyond fundamental knowledge to focus on the development of clinical judgment.Optimization of patient outcomes should be valued over performance of individual airway management skills.Credentialing and continuing education activities in airway management are essential to advance clinicians beyond entry-level competency.Initial and continuing education programs should be responsive to advances in the evidence base and maintain adaptability to re-assess content and expected outcomes on a continual basis.
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Affiliation(s)
- Maia Dorsett
- Received August 10, 2021 from Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY (MD); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH (ARP); Departments of Anesthesiology and Emergency Medicine, UTHealth McGovern Medical School, Houston, TX (CS); Department of Emergency Medicine, University of California San Diego (UCSD) San Diego California USA, San Diego, CA (AF); Office of the Chief Medical Officer, Austin-Travis County EMS, Austin, TX (WL); Departments of Anesthesiology and Emergency Medicine, University of Rochester Medical Center, Rochester, NY (CG); Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA (RT); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (TG). Revision received August 31, 2021; accepted for publication September 3, 2021
| | - Ashish R Panchal
- Received August 10, 2021 from Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY (MD); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH (ARP); Departments of Anesthesiology and Emergency Medicine, UTHealth McGovern Medical School, Houston, TX (CS); Department of Emergency Medicine, University of California San Diego (UCSD) San Diego California USA, San Diego, CA (AF); Office of the Chief Medical Officer, Austin-Travis County EMS, Austin, TX (WL); Departments of Anesthesiology and Emergency Medicine, University of Rochester Medical Center, Rochester, NY (CG); Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA (RT); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (TG). Revision received August 31, 2021; accepted for publication September 3, 2021
| | - Christopher Stephens
- Received August 10, 2021 from Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY (MD); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH (ARP); Departments of Anesthesiology and Emergency Medicine, UTHealth McGovern Medical School, Houston, TX (CS); Department of Emergency Medicine, University of California San Diego (UCSD) San Diego California USA, San Diego, CA (AF); Office of the Chief Medical Officer, Austin-Travis County EMS, Austin, TX (WL); Departments of Anesthesiology and Emergency Medicine, University of Rochester Medical Center, Rochester, NY (CG); Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA (RT); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (TG). Revision received August 31, 2021; accepted for publication September 3, 2021
| | - Andra Farcas
- Received August 10, 2021 from Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY (MD); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH (ARP); Departments of Anesthesiology and Emergency Medicine, UTHealth McGovern Medical School, Houston, TX (CS); Department of Emergency Medicine, University of California San Diego (UCSD) San Diego California USA, San Diego, CA (AF); Office of the Chief Medical Officer, Austin-Travis County EMS, Austin, TX (WL); Departments of Anesthesiology and Emergency Medicine, University of Rochester Medical Center, Rochester, NY (CG); Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA (RT); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (TG). Revision received August 31, 2021; accepted for publication September 3, 2021
| | - William Leggio
- Received August 10, 2021 from Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY (MD); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH (ARP); Departments of Anesthesiology and Emergency Medicine, UTHealth McGovern Medical School, Houston, TX (CS); Department of Emergency Medicine, University of California San Diego (UCSD) San Diego California USA, San Diego, CA (AF); Office of the Chief Medical Officer, Austin-Travis County EMS, Austin, TX (WL); Departments of Anesthesiology and Emergency Medicine, University of Rochester Medical Center, Rochester, NY (CG); Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA (RT); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (TG). Revision received August 31, 2021; accepted for publication September 3, 2021
| | - Christopher Galton
- Received August 10, 2021 from Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY (MD); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH (ARP); Departments of Anesthesiology and Emergency Medicine, UTHealth McGovern Medical School, Houston, TX (CS); Department of Emergency Medicine, University of California San Diego (UCSD) San Diego California USA, San Diego, CA (AF); Office of the Chief Medical Officer, Austin-Travis County EMS, Austin, TX (WL); Departments of Anesthesiology and Emergency Medicine, University of Rochester Medical Center, Rochester, NY (CG); Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA (RT); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (TG). Revision received August 31, 2021; accepted for publication September 3, 2021
| | - Rickquel Tripp
- Received August 10, 2021 from Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY (MD); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH (ARP); Departments of Anesthesiology and Emergency Medicine, UTHealth McGovern Medical School, Houston, TX (CS); Department of Emergency Medicine, University of California San Diego (UCSD) San Diego California USA, San Diego, CA (AF); Office of the Chief Medical Officer, Austin-Travis County EMS, Austin, TX (WL); Departments of Anesthesiology and Emergency Medicine, University of Rochester Medical Center, Rochester, NY (CG); Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA (RT); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (TG). Revision received August 31, 2021; accepted for publication September 3, 2021
| | - Tom Grawey
- Received August 10, 2021 from Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY (MD); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH (ARP); Departments of Anesthesiology and Emergency Medicine, UTHealth McGovern Medical School, Houston, TX (CS); Department of Emergency Medicine, University of California San Diego (UCSD) San Diego California USA, San Diego, CA (AF); Office of the Chief Medical Officer, Austin-Travis County EMS, Austin, TX (WL); Departments of Anesthesiology and Emergency Medicine, University of Rochester Medical Center, Rochester, NY (CG); Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA (RT); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (TG). Revision received August 31, 2021; accepted for publication September 3, 2021
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Lyng JW, Baldino KT, Braude D, Fritz C, March JA, Peterson TD, Yee A. Prehospital Supraglottic Airways: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:32-41. [PMID: 35001830 DOI: 10.1080/10903127.2021.1983680] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Supraglottic airway (SGA) devices provide effective conduits for oxygenation and ventilation and may offer protection from gastric aspiration. SGA devices are widely used by EMS clinicians as both rescue and primary airway management devices. While in common use for more than four decades, major developments in SGA education, science, and technology have influenced clinical strategies of SGA insertion and use in prehospital airway management for patients of all ages. NAEMSP recommends:SGAs have utility as a primary or secondary EMS airway intervention. EMS agencies should select SGA strategies that best suit available resources and local clinician skillset, as well as the nature of their clinical practice setting.EMS agencies that perform endotracheal intubation must also equip their clinicians with SGA devices and ensure adequate training and competence.In select situations, drug-assisted airway management may be used by properly credentialed EMS clinicians to facilitate SGA insertion.Confirmation of initial and continuous SGA placement using waveform capnography is strongly encouraged as a best practice.When it is functioning properly, EMS clinicians should refrain from converting an SGA to an endotracheal tube. The decision to convert an SGA to an endotracheal tube must consider the patient's condition, the effectiveness of SGA ventilations, and the clinical context and course of initial SGA insertionSGA training, competency, and clinical use must be continuously evaluated by EMS agencies using focused quality management programs.
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Hinkelbein J, Schmitz J, Mathes A, DE Robertis E. Performance of the laryngeal tube for airway management during cardiopulmonary resuscitation. Minerva Anestesiol 2020; 87:580-590. [PMID: 33300320 DOI: 10.23736/s0375-9393.20.14446-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Sudden cardiac arrest is one of the leading causes of death in Europe and the whole world. Effective chest compressions and advanced airway management have been shown to improve survival rates. Supraglottic airway devices such as the laryngeal tube (LT) are a well-known strategy for patients with cardiac arrest during both basic (BLS) and advanced life support (ALS). This systematic literature review aimed to summarize current data for using the LT when performing BLS and ALS. EVIDENCE ACQUISITION Recent data on the use of the LT during cardiopulmonary resuscitation (CPR) was gathered by using the Medline database and a specific search strategy. Terms were used in various order and combinations without time restrictions. A total of N.=1005 studies were identified and screened by two experienced anesthesiologists/emergency physicians independently. Altogether, data of N.=19 relevant papers were identified and included in the analysis. EVIDENCE SYNTHESIS Using the LT showed fast and easy placement with high success rates (76% to 94%) and was associated with higher short-term survival as compared to other strategies for initial airway management (2.2% vs. 1.4%). Quality of CPR such as chest compression fraction (CCF) before and after LT-insertion is improved (75% vs. 59%). For long-term survival, the LT showed lower survival rates. CONCLUSIONS Especially as initial device of airway management (for inexperienced staff), the use of a LT is easy and results in a fast insertion. The advantages of the LT as compared to bag mask ventilation and endotracheal intubation are inhomogeneous in recent literature.
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Affiliation(s)
- Jochen Hinkelbein
- Department for Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany -
| | - Jan Schmitz
- Department for Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Alexander Mathes
- Department for Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Edoardo DE Robertis
- Department of Surgical and Biomedical Sciences, Division of Anesthesia, Analgesia, and Intensive Care, University of Perugia, Perugia, Italy
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Hart D, Driver B, Kartha G, Reardon R, Miner J. Efficacy of Laryngeal Tube versus Bag Mask Ventilation by Inexperienced Providers. West J Emerg Med 2020; 21:688-693. [PMID: 32421521 PMCID: PMC7234713 DOI: 10.5811/westjem.2020.3.45844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/08/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Bag mask ventilation (BMV) and extraglottic devices (EGDs) are two common methods of providing rescue ventilation. BMV can be difficult to perform effectively, especially for inexperienced providers and in patients with difficult airway characteristics. There is some evidence that the laryngeal tube (LT) can be successfully placed by inexperienced providers to provide effective ventilation. However, it is unclear whether ventilation provided by LT is superior to that of BMV, especially in the hands of inexperienced airway providers. Therefore, we aimed to compare ventilation efficacy of inexperienced airway providers with BMV versus LT by primarily measuring tidal volumes and secondarily measuring peak pressures on a simulated model. METHODS We performed a crossover study first year emergency medicine residents and third and fourth year medical students. After a brief instructional video followed by hands on practice, participants performed both techniques in random order on a simulated model for two minutes each. Returned tidal volumes and peak pressures were measured. RESULTS Twenty participants were enrolled and 1200 breaths were measured, 600 per technique. The median ventilation volumes were 194 milliliters (mL) for BMV, and 387 mL for the laryngeal tube, with a median absolute difference of 170 mL (95% confidence interval [CI] 157-182 mL) (mean difference 148 mL [95% CI, 138-158 mL], p<0.001). The median ventilation peak pressures were 23 centimeters of water (cm H2O) for BMV, and 30 cm H2O for the laryngeal tube, with a median absolute difference of 7 cm H2O (95% CI, 6-8 cm H2O) (mean difference 8 cm H2O [95% CI, 7-9 cm H2O], p<0.001). CONCLUSION Inexperienced airway providers were able to provide higher ventilation volumes and peak pressures with the LT when compared to BMV in a manikin model. Inexperienced providers should consider using an LT when providing rescue ventilations in obtunded or hypoventilating patients without intact airway reflexes. Further study is required to understand whether these findings are generalizable to live patients.
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Affiliation(s)
- Danielle Hart
- Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Brian Driver
- Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Gautham Kartha
- Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Robert Reardon
- Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota
| | - James Miner
- Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota
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Chinn M, Biedrzycki L. Prehospital Laryngeal Tube Airway Device Placement Resulting in Hypopharyngeal Perforation: A Case Report. PREHOSP EMERG CARE 2019; 24:590-594. [PMID: 31550188 DOI: 10.1080/10903127.2019.1671565] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A 26-year-old female patient presented in cardiac arrest from presumed opioid overdose. An Ambu King LTS-D laryngeal device was placed by EMS providers for airway management during the resuscitation. There was no documented difficulty with placement and breath sounds and waveform capnography were consistent with appropriate placement. The resuscitation was terminated on scene after extensive resuscitative efforts by the EMS crew. Upon autopsy of the patient, it was discovered that the laryngeal tube device had caused a deep 5 cm perforation to the left piriform recess. The laryngeal tube had bent and was pushed into the perforation in the piriform recess; had the patient had regain of spontaneous circulation this could have caused significant morbidity. Laryngeal tube airway devices have shown increased usage in healthcare settings, in particular in the prehospital arena. Studies of these airway devices have shown they have quick insertion times, high success rates, and low complications. Tongue swelling and minor trauma are common complications of laryngeal tube airway devices. The case report describes a rare, yet potentially life-threatening, complication of laryngeal tube airway device placement- hypopharyngeal injury. If unrecognized, this injury could lead to serious complications. Providers should be aware of the common and uncommon injuries that are associated with prehospital laryngeal tube airway device placement.
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Yang Z, Liang H, Li J, Qiu S, He Z, Li J, Cao Z, Yan P, Liang Q, Zeng L, Liu R, Liang Z. Comparing the efficacy of bag-valve mask, endotracheal intubation, and laryngeal mask airway for subjects with out-of-hospital cardiac arrest: an indirect meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:257. [PMID: 31355224 DOI: 10.21037/atm.2019.05.21] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background For subjects with out-of-hospital cardiac arrest (OHCA), bag-valve mask (BVM), endotracheal intubation (ETI), and laryngeal mask airway (LMA) are the most common methods of ventilatory support; however, the best choice remains controversial. Methods A comprehensive search of online databases was performed. A traditional meta-analysis was performed to determine the risk ratio of BVM vs. LMA and ETI vs. LMA. Indirect treatment comparisons (ITCs) were conducted to compare BVM and ETI. Results A total of 13 full-text articles reporting the efficacy of BVM, ETI, and LMA were considered in this analysis. BVM and LMA had the same effect regarding return of spontaneous circulation (ROSC) (23% vs. 24%; RR =0.84), survival rate at admission (19% vs. 21%; RR =0.82) or discharge (6% vs. 4%; RR =0.61). ETI was superior to LMA in terms of ROSC (48% vs. 23%; RR =0.72) and survival rate at both admission (27% vs. 19%; RR =0.85) and discharge (12% vs. 4%; RR =0.90). BVM was inferior to ETI in terms of ROSC (24% vs. 48%; RR =0.86), survival to admission rate (21% vs. 27%; RR =1.037), and survival to discharge rate (6% vs. 12%; RR =1.476). Conclusions ETI should be considered for airway management as early as possible, which can improve the subject's success rate of recovery and survival to admission rate. In future, large-scale, multi-center, randomized controlled studies should be conducted to evaluate the exact efficacy of BVM, ETI, and LMA for the first aid of subjects with OHCA.
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Affiliation(s)
- Zhanzheng Yang
- Department of Emergency Room, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Hengrui Liang
- Depertment of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health (GIRH), State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Diseases, Guangzhou 510120, China
| | - Jiaying Li
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Shuxian Qiu
- Guangzhou Medical University, Guangzhou 510000, China
| | - Zhuosen He
- Department of Emergency Room, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Jinyin Li
- Department of Infirmary, Guangzhou School for The Visually Impaired, Guangzhou 510507, China
| | - Zanfeng Cao
- Department of Emergency Room, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Ping Yan
- Department of Emergency Room, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Qing Liang
- Department of Emergency Room, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Liangbo Zeng
- Department of Emergency Room, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Rong Liu
- Department of Emergency Room, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Zijing Liang
- Department of Emergency Room, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
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Granfeldt A, Avis SR, Nicholson TC, Holmberg MJ, Moskowitz A, Coker A, Berg KM, Parr MJ, Donnino MW, Soar J, Nation K, Andersen LW. Advanced airway management during adult cardiac arrest: A systematic review. Resuscitation 2019; 139:133-143. [PMID: 30981882 DOI: 10.1016/j.resuscitation.2019.04.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 03/29/2019] [Accepted: 04/02/2019] [Indexed: 01/10/2023]
Abstract
AIM To systematically review the literature on advanced airway management during adult cardiac arrest in order to inform the International Liaison Committee of Resuscitation (ILCOR) consensus on science and treatment recommendations. METHODS The review was performed according to PRISMA guidelines and registered on PROSPERO (CRD42018115556). We searched Medline, Embase, and Evidence-Based Medicine Reviews for controlled trials and observational studies published before October 30, 2018. The population included adult patients with cardiac arrest. Two investigators reviewed studies for relevance, extracted data, and assessed the risk of bias of individual studies. RESULTS We included 78 observational studies and 11 controlled trials. Most of the observational studies and all of the controlled trials only included patients with out-of-hospital cardiac arrest. The risk of bias for individual observational studies was overall assessed as critical or serious, with confounding and selection bias being the primary sources of bias. Three of the controlled trials, all published in 2018, were powered for clinical outcomes with two comparing a supraglottic airway to tracheal intubation and one comparing bag-mask ventilation to tracheal intubation. All three trials had some concerns regarding risk of bias primarily due to lack of blinding and variable adherence to the protocol. Clinical and methodological heterogeneity across studies, for both the observational studies and the controlled trials, precluded any meaningful meta-analyses. CONCLUSIONS We identified a large number of studies related to advanced airway management in adult cardiac arrest. Three recently published, large randomized trials in out-of-hospital cardiac arrest will help to inform future guidelines. Trials of advanced airway management during in-hospital cardiac arrest are lacking.
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Affiliation(s)
- Asger Granfeldt
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Suzanne R Avis
- School of Medicine, University of Tasmania - SydneyCampus, Sydney, Australia
| | | | - Mathias J Holmberg
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark; Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ari Moskowitz
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Amin Coker
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Katherine M Berg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michael J Parr
- Intensive Care Unit, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Michael W Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jasmeet Soar
- Intensive Care Unit, Southmead Hospital, Bristol, United Kingdom
| | - Kevin Nation
- New Zealand Resuscitation Council, Wellington, New Zealand
| | - Lars W Andersen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark; Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Intensive Care Medicine, Randers Regional Hospital, Randers, Denmark.
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Driver BE, Scharber SK, Horton GB, Braude DA, Simpson NS, Reardon RF. Emergency Department Management of Out-of-Hospital Laryngeal Tubes. Ann Emerg Med 2019; 74:403-409. [PMID: 30826068 DOI: 10.1016/j.annemergmed.2019.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/09/2019] [Accepted: 01/10/2019] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVE Laryngeal tubes are commonly used by emergency medical services (EMS) personnel for out-of-hospital advanced airway management. The emergency department (ED) management of EMS-placed laryngeal tubes is unknown. We seek to describe ED airway management techniques, success, and complications of patients receiving EMS laryngeal tubes. METHODS Using a keyword text search of ED notes, we identified patients who arrived at our ED with a laryngeal tube from 2010 through 2017. We performed structured chart and video reviews for all eligible patients. In our ED, emergency physicians perform all airway management, and there is no protocol dictating airway management for patients arriving with a laryngeal tube. Using descriptive methods, we report the techniques, success, and complications of ED airway management. RESULTS We analyzed data on 647 patients receiving out-of-hospital laryngeal tubes, including 472 (73%) with cardiac arrest from medical causes, 75 (21%) with cardiac arrest from trauma, and 100 (15%) with other conditions. For 580 patients (89%), emergency physicians exchanged the laryngeal tube for a definitive airway in the ED. Of the 67 patients not intubated in the ED, 66 died in the ED without further airway management. Of the 580 patients intubated in the ED, orotracheal intubation was the first method attempted for 578 (>99%) and was successful on the first attempt for 515 of 578 (89%). Macintosh video laryngoscopy (88% of initial attempts) and a bougie (68% of initial attempts) were commonly used adjuncts. For 345 of 578 patients (60%), the laryngeal tube was removed before intubation attempts. For 112 of 578 patients (19%), the first intubation attempt occurred with the deflated laryngeal tube left in place. Three patients (<1%) required a surgical airway. CONCLUSION In this cohort, emergency physicians successfully exchanged an out-of-hospital laryngeal tube for an endotracheal tube, using commonly available airway management techniques. ED clinicians should be familiar with techniques for exchanging out-of-hospital extraglottic airways for an endotracheal tube.
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Affiliation(s)
- Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.
| | | | - Gabriella B Horton
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Darren A Braude
- Departments of Emergency Medicine and Anesthesiology, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Nicholas S Simpson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
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Fiala A, Lederer W, Neumayr A, Egger T, Neururer S, Toferer E, Baubin M, Paal P. EMT-led laryngeal tube vs. face-mask ventilation during cardiopulmonary resuscitation - a multicenter prospective randomized trial. Scand J Trauma Resusc Emerg Med 2017; 25:104. [PMID: 29073915 PMCID: PMC5658918 DOI: 10.1186/s13049-017-0446-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 10/04/2017] [Indexed: 11/10/2022] Open
Abstract
Background Laryngeal tube (LT) application by rescue personnel as an alternate airway during the early stages of out-of-hospital cardiac arrest (OHCA) is still subject of debate. We evaluated ease of handling and efficacy of ventilation administered by emergency medical technicians (EMTs) using LT and bag-valve-mask (BVM) during cardiopulmonary resuscitation of patients with OHCA. Methods An open prospective randomized multicenter study was conducted at six emergency medical services centers over 18 months. Patients in OHCA initially resuscitated by EMTs were enrolled. Ease of handling (LT insertion, tight seal) and efficacy of ventilation (chest rises visibly, no air leak) with LT and BVM were subjectively assessed by EMTs during pre-study training and by the attending emergency physician on the scene. Outcome and frequency of complications were compared. Results Of 97 eligible patients, 78 were enrolled. During pre-study training EMTs rated efficacy of ventilation with LT higher than with BVM (66.7% vs. 36.2%, p = 0.022), but efficacy of on-site ventilation did not differ between the two groups (71.4% vs. 58.5%, p = 0.686). Frequency of complications (11.4% vs. 19.5%, p = 0.961) did not differ between the two groups. Conclusions EMTs preferred LT ventilation to BVM ventilation during pre-study training, but on-site there was no difference with regard to efficacy, ventilation safety, or outcome. The results indicate that LT ventilation by EMTs during OHCA is not superior to BVM and cannot substitute for BVM training. We assume that the main benefit of the LT is the provision of an alternative airway when BVM ventilation fails. Training in BVM ventilation remains paramount in EMT apprenticeship and cannot be substituted by LT ventilation. Trial registration ClinicalTrials.gov (NCT01718795). Electronic supplementary material The online version of this article (10.1186/s13049-017-0446-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Fiala
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Wolfgang Lederer
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Agnes Neumayr
- Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Tamara Egger
- Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Sabrina Neururer
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Ernst Toferer
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Michael Baubin
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Teaching Hospital of the Paracelsus Private Medical University Salzburg, Salzburg, Austria.,Barts Heart Centre, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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Jarman AF, Hopkins CL, Hansen JN, Brown JR, Burk C, Youngquist ST. Advanced Airway Type and Its Association with Chest Compression Interruptions During Out-of-Hospital Cardiac Arrest Resuscitation Attempts. PREHOSP EMERG CARE 2017; 21:628-635. [PMID: 28459305 DOI: 10.1080/10903127.2017.1308611] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To assess interruptions in chest compressions associated with advanced airway placement during cardiopulmonary resuscitation (CPR) of out-of-hospital cardiac arrest (OHCA) victims. METHODS The method used was observational analysis of prospectively collected clinical and defibrillator data from 339 adult OHCA victims, excluding victims with <5 minutes of CPR. Interruptions in CPR, summarized by chest compression fraction (CCF), longest pause, and the number of pauses greater than 10 seconds, were compared between patients receiving bag valve mask (BVM), supraglottic airway (SGA), endotracheal intubation (ETI) via direct laryngoscopy (DL), and ETI via video laryngoscopy (VL). Secondary outcomes included first pass success and the effect of multiple airway attempts on CPR interruptions. RESULTS During the study period, paramedics managed 23 cases with BVM, 43 cases with SGA, 148 with DL, and 125 with VL. There were no statistically significant differences between the airway groups with regard to longest compression pause (BVM 18 sec [IQR 11-33], SGA 29 sec [IQR 15-65], DL 26 sec [IQR 12-59], VL 22 sec [IQR 14-41]), median number of pauses greater than 10 seconds (BVM 2 [IQR 1-3], SGA 2 [IQR 1-3], DL 2 [IQR 1-4], VL 2 [IQR 1-3]), or CCF (0.92 for all groups). However, each additional attempt following failed initial DL was associated with an increase in the risk of additional chest compression pauses (relative risk 1.29, 95% confidence interval 1.02-1.64). Such an association was not observed with additional attempts using VL or SGA. First pass success was highest with SGA (77%), followed by between DL (68%) and VL (67%); these differences were not statistically significant. CONCLUSIONS While summary measures of chest compression delivery did not differ significantly between airway classes in this observational study, repeated attempts following failed initial DL during cardiopulmonary resuscitation were associated with an increase in the number of pauses in chest compression delivery observed.
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Roth D, Schreiber W, Herkner H. Safety of laryngeal tubes- the authors reply. Am J Emerg Med 2016; 34:311. [DOI: 10.1016/j.ajem.2015.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/02/2015] [Indexed: 11/28/2022] Open
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Oberhammer R, Gruber E, Brugger H, Strapazzon G, Procter E. Safety of laryngeal tubes. Am J Emerg Med 2016; 34:310-1. [DOI: 10.1016/j.ajem.2015.10.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 10/16/2015] [Indexed: 11/30/2022] Open
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