9/20/18

1

Airway Rescue with Supraglottic Devices

James Rich, CRNASLAM Airway Training Institute

Airway Rescue with Supraglottic Devices

2

Rescue Ventilation is Born

Thank You Archie Brain

Archie Brain received the Benefactor of Mankind Award from the Airway Education & Research Foundation –September 16, 2000

Rescue Ventilation Pathway

•Rescue Ventilation with any FDA Approved SGA.

EMERGENCY USE OF THE LMAMIGHT BE USED IN EMERGENCIES

þ Cardiac arrest

þ Near drowning

þ Drug overdose

þ Smoke inhalation / toxic fumes

þ Cannot Ventilate – Cannot Intubate

þ Trauma - including in those with head/facial trauma unable to maintain airway or oxygenation.

Ü The LMA does not afford complete protection against gastric regurgitation and pulmonary aspiration. However…

ÜDuring CPR the LMA does provide significantly greater protection against aspiration than occurs with mouth-to-mouth / pocket mask / automatic resuscitator / bag-valve-mask ventilation, with or without an O/P or N/P airway

Ü The level of protection is enhanced when the LMA is used as the sole airway adjunct from the outset of resuscitation

Ü The cuff of the LMA also helps to guard against the aspiration of blood arising from oral or nasal cavities.

PULMONARY ASPIRATION AND THE LMA

9/20/18

2

THE LARYNGEAL MASK AIRWAY

Ü Placement easier to learn

Ü Higher levels of skill retention over time

Ü Higher first-time placement rates

Ü Shorter time to achieve an adequate airway

Ü Plentiful supply of routine cases on which to gain experience

Ü Laryngoscopy unnecessary

Ü Neuromuscular blockade not required

Ü Avoids risk of oesophageal & endobronchial placement

Ü Placement easily achieved with MILS of cervical spine applied

Ü Less invasive of and traumatic to the respiratory tract

Ü Lower incidence of bacteraemia & laryngospasm

Ü Avoidance of barotrauma to lungs.

Advantages over the tracheal tube:THE LARYNGEAL MASK AIRWAY

Ü Airway less effectively secured - the cuffed tracheal tube remains the ‘Gold Standard’ airway device

Ü Airway obstruction at glottic and subglottic level cannot be prevented

Ü Oropharyngeal leakage and gastric insufflation are more likely to occur

Ü Ventilation pressures over 20 (or 30) cmH2O not possible

Ü Fixation said to require greater spatial awareness with possible higher risk of dislodgement

Ü Cost

Ü Increased risk of aspiration?

Disadvantages compared with the tracheal tube:

THE LARYNGEAL MASK AIRWAYDisadvantages compared with the tracheal tube:

Ü Airway less effectively secured - the cuffed tracheal tube remains the ‘Gold Standard’ airway device

Ü Airway obstruction at glottic and subglottic level cannot be prevented

Ü Oropharyngeal leakage and gastric insufflation are more likely to occur

Ü Ventilation pressures over 20 (or 30) cmH2O not possible

Ü Fixation said to require greater spatial awareness with possible higher risk of dislodgement

Ü Cost

Ü Increased risk of aspiration? Not according to

THE LARYNGEAL MASK AIRWAY

Disadvantages compared with the tracheal tube:

Ü Increased risk of aspiration? Not according to

meta-analysis study by Brimacombe.

Ü Airway less effectively secured - the cuffed tracheal tube

remains the ‘Gold Standard’ airway device

Ü Airway obstruction at glottic and subglottic level cannot be prevented

Ü Oropharyngeal leakage and gastric insufflation are more

likely to occur

Ü Ventilation pressures over 20 (or 30) cmH2O not possible

Ü Fixation said to require greater spatial awareness with possible higher risk of dislodgement

Ü Cost

PITFALLS ASSOCIATED with LARYNGOSCOPIC TRACHEAL INTUBATION

Ü Scarcity of specialist anaesthetists in this environment

Ü Need for non-specialists to undertake regular practice to maintain intubation skills (with shrinking opportunities)

Ü Limited availability of anaesthetic agents/neuromuscular blockers amongst pre-hospital care providers

Ü Equipment issues (dead batteries, blown bulb, etc.)

Ü Poor vision of larynx due to blood & secretions

Ü Hypoxaemia associated with repeated/prolonged attempts

Ü Risk of undetected oesophageal or endobronchial tube placement

Ü Potential for aggravation of cervical spine trauma

Ü Restricted access to trapped casualties.

1. Drugs are not required for Cardiac Arrest patients or for those who are deeply unconscious with absent glossopharyngeal reflexes(Tip - patients who will tolerate an O/P airway will often tolerate careful insertion of an LMA)

2. ‘Judicious Sedation’ can be employed to facilitate LMA insertion in those who are not fully obtunded, (using midazolam, etomidate, propofol, etc.)

3. Neuromuscular blocking agents are not necessary for the insertion of LMA devices

4. The LMA is tolerated at lighter levels of sedationthan the tracheal tube.

DRUGS TO FACILITATE LMA INSERTION

9/20/18

3

EXHALATION

Inhalation/Exhalation

WHEN THE LMA IS CORRECTLY INSERTEDIT PROVIDES A CLEAR SUPRAGLOTTIC PATHWAY

CORRECT ORIENTATION OF INSERTING HANDDURING STANDARD INSERTION TECHNIQUE

T RA C

H E A

O E SO P H

A GU S

L A R Y N X

Keep wristwell flexed

Push index finger towards palm

of opposite hand

Allow the palato-pharyngeal curve to guide the mask

into position

LMA Inflation Volumes

• LMA #3 - 20 mL• LMA #4 - 30 mL• LMA #5 - 40 mL• LMA #6 - 50 mL

Problems with LMA Insertion

9/20/18

4

King LT

• Insert• Inflate• Pull Back• Ventilate

9/20/18

5