Skills retention for insertion of the Combitube and laryngeal mask airway

Prehospital advanced airway management for trauma in the United Kingdom: how, when and by whom?

Advanced airway management in the prehospital arena remains controversial. This paper aims to explore some of the evidence and options available and propose a way forward. Options for provision of, and training in, pre-hospital emergency anaesthesia are explored and alternative strategies are discussed. Where classical rapid sequence induction of anaesthesia proves impractical for operational reasons or due to lack of facilities, training opportunities or skills maintenance, a potential ‘silver standard’ is suggested as an alternative.

Procedural instruction in invasive bedside procedures: a systematic review and meta-analysis of effective teaching approaches

IMPORTANCE

Optimal approaches to teaching bedside procedures are unknown.

OBJECTIVE

To identify effective instructional approaches in procedural training.

DATA SOURCES

We searched PubMed, EMBASE, Web of Science and Cochrane Library through December 2014.

STUDY SELECTION

We included research articles that addressed procedural training among physicians or physician trainees for 12 bedside procedures. Two independent reviewers screened 9312 citations and identified 344 articles for full-text review.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data from full-text articles.

MAIN OUTCOMES AND MEASURES

We included measurements as classified by translational science outcomes T1 (testing settings), T2 (patient care practices) and T3 (patient/public health outcomes). Due to incomplete reporting, we post hoc classified study outcomes as 'negative' or 'positive' based on statistical significance. We performed meta-analyses of outcomes on the subset of studies sharing similar outcomes.

RESULTS

We found 161 eligible studies (44 randomised controlled trials (RCTs), 34 non-RCTs and 83 uncontrolled trials). Simulation was the most frequently published educational mode (78%). Our post hoc classification showed that studies involving simulation, competency-based approaches and RCTs had higher frequencies of T2/T3 outcomes. Meta-analyses showed that simulation (risk ratio (RR) 1.54 vs 0.55 for studies with vs without simulation, p=0.013) and competency-based approaches (RR 3.17 vs 0.89, p<0.001) were effective forms of training.

CONCLUSIONS AND RELEVANCE

This systematic review of bedside procedural skills demonstrates that the current literature is heterogeneous and of varying quality and rigour. Evidence is strongest for the use of simulation and competency-based paradigms in teaching procedures, and these approaches should be the mainstay of programmes that train physicians to perform procedures. Further research should clarify differences among instructional methods (eg, forms of hands-on training) rather than among educational modes (eg, lecture vs simulation).

Essentials of airway management, oxygenation, and ventilation: part 2: advanced airway devices: supraglottic airways

Offices and outpatient dental facilities must be properly equipped with devices for airway management, oxygenation, and ventilation. Part 1 in this series on emergency airway management focused on basic and fundamental considerations for supplying supplemental oxygen to the spontaneously breathing patient and utilizing a bag-valve-mask system including nasopharyngeal and oropharyngeal airways to deliver oxygen under positive pressure to the apneic patient. This article will review the evolution and use of advanced airway devices, specifically supraglottic airways, with the emphasis on the laryngeal mask airway, as the next intervention in difficult airway and ventilation management. The final part of the series (part 3) will address airway evaluation, equipment and devices for tracheal intubation, and invasive airway procedures.

Supreme Laryngeal Mask Airway achieves faster insertion times than Classic LMA during chest compressions in manikins

BACKGROUND

According to the 2010 European Resuscitation Council guidelines on cardiopulmonary resuscitation (CPR), one can appreciate that the classic laryngeal mask airway (CLMA) is acceptable as an alternative airway device to endotracheal intubation for airway management in cardiac arrest victims.

OBJECTIVE

To compare a relatively new supraglottic airway device, the Supreme Laryngeal Mask Airway (SLMA), with the CLMA in a cardiac arrest scenario.

METHODS

Fifty healthcare professionals inexperienced in advanced airway management attempted to insert both airway devices in a manikin in 2 scenarios: in the first, chest compressions were not performed (non-CPR scenario), and in the second, uninterrupted chest compressions were performed (CPR scenario). The primary end points were insertion time and success rate at first attempt. The level of self-confidence of each participant was recorded.

RESULTS

SLMA achieves faster insertion times both in the non-CPR (SLMA: 10.4 ± 2.7 seconds vs CLMA: 13.4 ± 3.2 seconds, P < .05) and in the CPR scenario (SLMA: 9.9 ± 2.0 seconds Vs CLMA: 11.9 ± 2.3 seconds, P < .05). The difference between first attempt success rates was not statistically significant both in the non-CPR (SLMA: 96% vs CLMA: 90%, P = .18) and in the CPR scenario (SLMA: 98% vs CLMA: 94%, P = .32). The participants are more self-confident using SLMA instead of CLMA (P < .001) and 94% of them would prefer SLMA for future use.

CONCLUSION

SLMA could be a useful alternative to CLMA during CPR in the hands of healthcare professionals with minimal experience in airway management.

Effects of bag-mask versus advanced airway ventilation for patients undergoing prolonged cardiopulmonary resuscitation in pre-hospital setting

BACKGROUND

There is no evidence that the advanced airway ventilation (AAV) method improves patient outcome in the pre-hospital cardiac arrest setting.

OBJECTIVE

The aim of this study was to estimate the effectiveness of AAV vs. bag-mask ventilation (BMV) for cardiopulmonary arrest (CPA) patients, when administered by a licensed emergency medical technician in the pre-hospital setting.

METHODS

The study used the database of patients who suffered out-of-hospital cardiogenic CPA from 2006 to 2007 in our hospital. Patient records were searched for the method of pre-hospital airway management (BMV or AAV) and the patient's outcomes were compared between groups. The primary endpoint was a favorable neurological outcome; the secondary endpoints were rate of return of spontaneous circulation (ROSC) and rate of admission to the intensive care unit (ICU).

RESULTS

A total of 355 CPA patients (156 BMV and 199 AAV) were retrospectively enrolled. There was no significant difference in demographics between the two groups. The transportation time exceeded 30 min in both groups. The overall ROSC rate and ICU admission rate were significantly higher in the AAV group (p = 0.0352 and p = 0.0089, respectively). The data showed that AAV (odds ratio 1.960; 95% confidence interval 1.015-3.785) resulted in a higher overall ROSC rate than BMV, but there were no significant differences in either the rate of pre-hospital ROSC or in favorable neurological outcome.

CONCLUSION

AAV may yield advantages over BMV in the overall rate of ROSC in CPA patients, but both approaches for airway management in this study resulted in a comparably favorable neurological outcome. Earlier ROSC would be required for improved overall outcome.

Laypersons can successfully place supraglottic airways with 3 minutes of training. A comparison of four different devices in the manikin

INTRODUCTION

Supraglottic airway devices have frequently been shown to facilitate airway management and are implemented in the ILCOR resuscitation algorithm. Limited data exists concerning laypersons without any medical or paramedical background. We hypothesized that even laymen would be able to operate supraglottic airway devices after a brief training session.

METHODS

Four different supraglottic airway devices: Laryngeal Mask Classic (LMA), Laryngeal Tube (LT), Intubating Laryngeal Mask (FT) and CobraPLA (Cobra) were tested in 141 volunteers recruited in a technical university cafeteria and in a shopping mall. All volunteers received a brief standardized training session. Primary endpoint was the time required to definitive insertion. In a short questionnaire applicants were asked to assess the devices and to answer some general questions about BLS.

RESULTS

The longest time to insertion was observed for Cobra (31.9 ± 27.9 s, range: 9-120, p < 0.0001; all means ± standard deviation). There was no significant difference between the insertion times of the other three devices. Fewest insertion attempts were needed for the FT (1.07 ± 0.26), followed by the LMA (1.23 ± 0.52, p > 0.05), the LT (1.36 ± 0.61, p < 0.05) and the Cobra (1.45 ± 0.7, p < 0.0001). Ventilation was achieved on the first attempt significantly more often with the FT (p < 0.001) compared to the other devices. Nearly 90% of the participants were in favor of implementing supraglottic airway devices in first aid algorithms and classes.

CONCLUSION

Laypersons are able to operate supraglottic airway devices in manikin with minimal instruction. Ventilation was achieved with all devices tested after a reasonable time and with a high success rate of > 95%. The use of supraglottic airway devices in first aid and BLS algorithms should be considered.

The effects of laryngeal mask airway passage simulation training on the acquisition of undergraduate clinical skills: a randomised controlled trial

BACKGROUND

Effective use of the laryngeal mask airway (LMA) requires learning proper insertion technique in normal patients undergoing routine surgical procedures. However, there is a move towards simulation training for learning practical clinical skills, such as LMA placement. The evidence linking different amounts of mannequin simulation training to the undergraduate clinical skill of LMA placement in real patients is limited. The purpose of this study was to compare the effectiveness in vivo of two LMA placement simulation courses of different durations.

METHODS

Medical students (n = 126) enrolled in a randomised controlled trial. Seventy-eight of these students completed the trial. The control group (n = 38) received brief mannequin training while the intervention group (n = 40) received additional more intensive mannequin training as part of which they repeated LMA insertion until they were proficient. The anaesthetists supervising LMA placements in real patients rated the participants' performance on assessment forms. Participants completed a self-assessment questionnaire.

RESULTS

Additional mannequin training was not associated with improved performance (37% of intervention participants received an overall placement rating of > 3/5 on their first patient compared to 48% of the control group, X2 = 0.81, p = 0.37). The agreement between the participants and their instructors in terms of LMA placement success rates was poor to fair. Participants reported that mannequins were poor at mimicking reality.

CONCLUSIONS

The results suggest that the value of extended mannequin simulation training in the case of LMA placement is limited. Educators considering simulation for the training of practical skills should reflect on the extent to which the in vitro simulation mimics the skill required and the degree of difficulty of the procedure.

Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.

The intuitive use of laryngeal airway tools by first year medical students

Background

Providing a secured airway is of paramount importance in cardiopulmonary resuscitation. Although intubating the trachea is yet seen as gold standard, this technique is still reserved to experienced healthcare professionals. Compared to bag-valve facemask ventilation, however, the insertion of a laryngeal mask airway offers the opportunity to ventilate the patient effectively and can also be placed easily by lay responders. Obviously, it might be inserted without detailed background knowledge.

The purpose of the study was to investigate the intuitive use of airway devices by first-year medical students as well as the effect of a simple, but well-directed training programme. Retention of skills was re-evaluated six months thereafter.

Methods

The insertion of a LMA-Classic and a LMA-Fastrach performed by inexperienced medical students was compared in an airway model. The improvement on their performance after a training programme of overall two hours was examined afterwards.

Results

Prior to any instruction, mean time to correct placement was 55.5 ± 29.6 s for the LMA-Classic and 38.1 ± 24.9 s for the LMA-Fastrach. Following training, time to correct placement decreased significantly with 22.9 ± 13.5 s for the LMA-Classic and 22.9 ± 19.0 s for the LMA-Fastrach, respectively (p < 0.05). After six months, the results are comparable prior (55.6 ± 29.9 vs 43.1 ± 34.7 s) and after a further training period (23.5 ± 13.2 vs 26.6 ± 21.6, p < 0.05).

Conclusion

Untrained laypersons are able to use different airway devices in a manikin and may therefore provide a secured airway even without having any detailed background knowledge about the tool. Minimal theoretical instruction and practical skill training can improve their performance significantly. However, refreshment of knowledge seems justified after six months.

Comparison of the Glidescope and Pentax AWS laryngoscopes to the Macintosh laryngoscope for use by advanced paramedics in easy and simulated difficult intubation

Background

Intubation of the trachea in the pre-hospital setting may be lifesaving in severely ill and injured patients. However, tracheal intubation is frequently difficult to perform in this challenging environment, is associated with a lower success rate, and failed tracheal intubation constitutes an important cause of morbidity. Novel indirect laryngoscopes, such as the Glidescope^® and the AWS^® laryngoscopes may reduce this risk.

Methods

We compared the efficacy of these devices to the Macintosh laryngoscope when used by 25 Advanced Paramedics proficient in direct laryngoscopy, in a randomized, controlled, manikin study. Following brief didactic instruction with the Glidescope^® and the AWS^® laryngoscopes, each participant took turns performing laryngoscopy and intubation with each device, in an easy intubation scenario and following placement of a hard cervical collar, in a SimMan^® manikin.

Results

Both the Glidescope^® and the AWS^® performed better than the Macintosh, and demonstrate considerable promise in this context. The AWS^® had the least number of dental compressions in all three scenarios, and in the cervical spine immobilization scenario it required fewer maneuvers to optimize the view of the glottis.

Conclusion

The Glidescope^® and AWS^® devices possess advantages over the conventional Macintosh laryngoscope when used by Advanced Paramedics in normal and simulated difficult intubation scenarios in this manikin study. Further studies are required to extend these findings to the clinical setting.

Comparison of the Airtraq and Truview laryngoscopes to the Macintosh laryngoscope for use by Advanced Paramedics in easy and simulated difficult intubation in manikins

BACKGROUND

Paramedics are frequently required to perform tracheal intubation, a potentially life-saving manoeuvre in severely ill patients, in the prehospital setting. However, direct laryngoscopy is often more difficult in this environment, and failed tracheal intubation constitutes an important cause of morbidity. Novel indirect laryngoscopes, such as the Airtraq and Truview laryngoscopes may reduce this risk.

METHODS

We compared the efficacy of these devices to the Macintosh laryngoscope when used by 21 Paramedics proficient in direct laryngoscopy, in a randomized, controlled, manikin study. Following brief didactic instruction with the Airtraq and Truview laryngoscopes, each participant took turns performing laryngoscopy and intubation with each device, in an easy intubation scenario and following placement of a hard cervical collar, in a SimMan manikin.

RESULTS

The Airtraq reduced the number of optimization manoeuvres and reduced the potential for dental trauma when compared to the Macintosh, in both the normal and simulated difficult intubation scenarios. In contrast, the Truview increased the duration of intubation attempts, and required a greater number of optimization manoeuvres, compared to both the Macintosh and Airtraq devices.

CONCLUSION

The Airtraq laryngoscope performed more favourably than the Macintosh and Truview devices when used by Paramedics in this manikin study. Further studies are required to extend these findings to the clinical setting.

Alternative airway devices for use in children requiring prehospital airway management: update and case discussion

This manuscript reviews the latest literature on alternative airways for use in children requiring prehospital airway management. Case discussions serve as a springboard for discussion of alternatives to bag-mask ventilation and endotracheal intubation for management of ventilation in infants and children in the prehospital setting. Few airway procedures have been studied with any rigor in this setting, and most of the data that are available are extrapolated from adults. Laryngeal mask airway may be the best alternative airway with the most promise to add to the armamentarium of the prehospital provider, but no controlled trial to date has been conducted.

Randomized comparison of the SLIPA (Streamlined Liner of the Pharynx Airway) and the SS-LM (Soft Seal Laryngeal Mask) by medical students

OBJECTIVE

The aim of the study was to compare the Streamlined Liner of the Pharynx Airway (SLIPA; Hudson RCI), a new supraglottic airway device, with the Soft Seal Laryngeal Mask (SS-LM; Portex) when used by novices.

METHODS

Thirty-six medical students with no previous airway experience, received manikin training in the use of the SLIPA and the SS-LM. Once proficient, the students inserted each device in randomized sequence, in two separate patients in the operating theatre. Only two insertion attempts per patient were allowed. Students were assessed in terms of: device preference; success or failure; success at first attempt and time to ventilation.

RESULTS

Sixty-seven per cent of the students preferred to use the SLIPA (95% confidence interval 49-81%). The SLIPA was successfully inserted (one or two attempts) in 94% of patients (34/36) and the SS-LM in 89% (32/36) (P = 0.39). First attempt success rates were 83% (30/36) and 67% (24/36) in the SLIPA and SS-LM, respectively (P = 0.10). Median time to ventilation was shorter with the SLIPA (40.6 s) than with the SS-LM (66.9 s) when it was the first device used (P = 0.004), but times were similar when inserting the second device (43.8 s vs 42.9 s) (P = 0.75).

CONCLUSIONS

In the present study novice users demonstrated high success rates with both devices. The SLIPA group achieved shorter times to ventilation when it was the first device they inserted, which might prove to be of clinical significance, particularly in resuscitation attempts. Although the Laryngeal Mask has gained wide recognition for use by both novice users and as a rescue airway in failed intubation, the data presented here suggest that the SLIPA might also prove useful in these areas.

Tracheal intubation by inexperienced medical residents using the Airtraq and Macintosh laryngoscopes--a manikin study

The Airtraq laryngoscope is a novel intubation device that may possess advantages over conventional direct laryngoscopes for use by personnel that are infrequently required to perform tracheal intubation. We conducted a prospective study in 20 medical residents with little prior airway management experience. After brief didactic instruction, each participant took turns performing laryngoscopy and intubation using the Macintosh (Welch Allyn, Welch Allyn, NY) and Airtraq (Prodol Ltd. Vizcaya, Spain) devices, in 3 laryngoscopy scenarios in a Laerdal Intubation Trainer (Laerdal, Stavanger, Norway) and 1 scenario in a Laerdal SimMan manikin (Laerdal, Kent, UK). They then performed tracheal intubation of the normal airway a second time to characterize the learning curve. In all scenarios tested, the Airtraq decreased the duration of intubation attempts, reduced the number of optimization maneuvers required, and reduced the potential for dental trauma. The residents found the Airtraq easier to use in all scenarios compared with the Macintosh laryngoscope. The Airtraq may constitute a superior device for use by personnel infrequently required to perform tracheal intubation.

Acute management of sudden cardiac death in adults based upon the new CPR guidelines

PURPOSE OF THE REVIEW

The aim of this article is to provide a comprehensive description of interventions that can improve outcomes in adults with sudden cardiac death. The new American Heart Association 2005 Guidelines introduced a number of changes for the initial management of cardiorespiratory arrest based on new data that accumulated over the last 5 years.

ACUTE MANAGEMENT OF SUDDEN CARDIAC DEATH

Appropriate interventions targeting the three phases of cardiopulmonary resuscitation (CPR) (electrical, circulatory, and metabolic) should be implemented. Early defibrillation in early witnessed arrest with one shock is very effective and can improve survival outcomes. When resuscitation efforts are delayed and CPR is performed by paramedics, 2 min of CPR before shock is recommended. Emphasis has been placed on fast and forceful continuous compressions with minimal interruptions, adequate decompression, and decrease in the rate of ventilations to 8-10/min for intubated patients with two rescuers and a universal increase in compression to ventilation ratio to 30:2 for lone rescuers. Mechanical adjuncts to improve circulation have been adapted in the recommendations. The inspiratory impedance threshold device that enhances negative intrathoracic pressure and improves venous preload has been recommended for application in intubated and bag-mask ventilated patients. Owing to the difficulty of endotracheal intubation, airway management devices (Combitube and Laryngeal Mask Airway) can be used as alternatives with minimal extra training.

CONCLUSION

The new guidelines for CPR have focused on early defibrillation, uninterrupted compressions, complete decompression, fewer ventilations, and simplification and uniformity of the process.

Alternative management techniques for the difficult airway: esophageal-tracheal Combitube

PURPOSE OF REVIEW

To summarize knowledge about the esophageal-tracheal Combitube in emergency medicine and anesthesia, with special emphasis on uncommon indications. Papers published between August 2003 and July 2004 are reviewed.

RECENT FINDINGS

Tracheal intubation in the field is difficult and success rates are dependent upon training level (90-98%). Therefore, the esophageal-tracheal Combitube has been recommended for emergency ventilation after failed tracheal intubation with success rates of about 90%, even when performed by emergency medical technicians. Combitube insertion is easy to learn, but practice is necessary to retain skills. Use of this device has also been recommended for ventilatory support during routine anesthesia. Combitube ventilation is successful in over 96% of patients, with minimal trauma. Since only a small percentage of American anesthesiologists are familiar with the Combitube (<50%), using the device in anesthesia care may improve the skills required during emergency airway management. Blood gases are in the range of those obtained during endotracheal tube ventilation and aspiration prophylaxis is at least as good as that of the laryngeal mask airway. Successful uncommon uses of the device have also been recommended, for example, Combitube ventilation in craniomaxillomandibular surgery via the submental route and insertion of the device in a burns patient with minimal mouth opening and significant tracheal stenosis after long-term ventilation.

SUMMARY

The esophageal-tracheal Combitube is a useful and efficient alternative airway characterized by high success rates in emergency situations. We recommend the use of a laryngoscope for insertion and strict adherence to the manufacturer's guidelines in order to maximize success and minimize potential injury.