Comparison of the intubating laryngeal mask airway and laryngeal tube placement during manual in-line stabilisation of the neck

Comparison of Videolaryngoscope and Intubating Laryngeal Mask Airway for Tracheal Intubation with Manual-in-line Stabilization in Patients Undergoing Cervical Spine Surgery

Background:

This prospective, randomized study compared CMAC^® videolaryngoscope with intubating laryngeal mask airway (ILMA) for intubation under manual-in-line-stabilization (MILS) in patients undergoing cervical spine surgery. Settings and Design: Sixty-five ASA Physical Status Classes I and II patients aged 18–65 years undergoing elective cervical spine surgery were randomly allocated into two groups: group CM-intubation with CMAC^® videolaryngoscope (n = 33) and Group IL-intubation using ILMA (n = 32).

Materials and Methods:

Intubation was performed in all patients after the application of MILS. The primary outcomes included first attempt and overall intubation success rate, intubation time, and apnea time. The secondary objectives were degree of head movement, hemodynamic response, incidence of desaturation, sore throat, and tissue injury.

Statistical Analysis:

Normality of data was tested by the Kolmogorov–Smirnov test. Quantitative variables were compared using the unpaired t-test or Wilcoxon Mann–Whitney test and qualitative variables were compared using the Chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant.

Results:

CM group had a higher first attempt (96.97%, P = 0.054) and overall (100%, P = 0.053) intubation success rate than IL group (81.25% and 87.5%, respectively). Group CM had a significantly shorter (P < 0.0001) intubation time (33.13 ± 11.82 s) than IL group (55.71 ± 19.28 s), but group CM had significantly longer (P < 0.0001) apnea time (33.13 ± 11.82 s) than IL group (22.03 ± 7.14 s). The incidence of head movement was significantly lower in IL group (P = 0.011). Hypoxemia did not occur. Postintubation hemodynamic changes and tissue injury were significantly higher in ILMA group.

Conclusion:

CMAC group had higher intubation success rate and significantly shorter intubation time. However, ILMA group had a significantly shorter apnea time and significantly lower incidence of head movements.

Insertion Success of the Laryngeal Tube in Emergency Airway Management

Background. Emergency airway management (AM) is a priority when resuscitating critically ill or severely injured patients. The goal of this study was to determine the success rates of LT insertion during AM. Methods. Studies that included LT first-pass insertion (FPI) and overall-pass insertion (OPI) success by emergency medical services and in-hospital providers performing AM for emergency situations as well as for scheduled surgery published until July 2014 were searched systematically in Medline. Results. Data of 36 studies (n = 1,897) reported a LT FPI success by physicians of 82.5% with an OPI success of 93.6% (p < 0.001). A cumulative analysis of all 53 studies (n = 3,600) led to FPI and OPI success of 80.1% and 92.6% (p < 0.001), respectively. The results of 26 studies (n = 2,159) comparing the LT with the laryngeal mask airway (LMA) demonstrated a FPI success of 77.0 versus 78.7% (p = 0.36) and an OPI success of 92.2 versus 97.7% (p < 0.001). Conclusion. LT insertion failed in the first attempt in one out of five patients, with an overall failure rate in one out of 14 patients. When compared with the LT, the LMA had a cumulative 5.5% better OPI success rate.

Comparison of the Macintosh, McCoy, Airtraq laryngoscopes and the intubating laryngeal mask airway in a difficult airway with manual in-line stabilisation: a cross-over simulation-based study

CONTEXT

Patients with multisystem trauma undergoing intubation with manual in-line stabilisation (MILS) have a higher incidence of difficult or failed intubations.

OBJECTIVE

To compare the effectiveness of the Macintosh laryngoscope with three other intubating devices in a high fidelity simulation model.

DESIGN

Cross-over, simulation-based study.

SETTING

Tertiary referral and level 1 trauma centre between June and November 2011.

PARTICIPANTS

Thirty-five experienced airway physicians.

INTERVENTION

Each participant performed tracheal intubations on a Laerdal SimMan manikin in both a normal airway and a difficult airway scenario with MILS. The devices utilised in a randomised order were the Macintosh, McCoy, Airtraq laryngoscopes and the intubating laryngeal mask airway (iLMA).

MAIN OUTCOME MEASURES

The primary outcome was time to intubation. Success rates, grade of laryngoscopy and force of intubation were also measured.

RESULTS

One hundred and forty intubations were attempted by 35 participants in both the normal and MILS scenarios. In the normal airway, there was no difference in success rates and time to intubation. In the difficult airway with MILS, there was no difference in success rates. However, the Airtraq was associated with a longer time to intubation than the Macintosh, McCoy and iLMA, 39.3, 26.7, 23.3, 39.3, 22.8 s, respectively (P < 0.0001). The Airtraq delivered the best glottic view and lowest force of intubation in both scenarios (P < 0.0001), but was associated with the only failed intubation in the study. The McCoy was associated with a significant improvement in the glottic visualisation (P < 0.05) and reduction in the force of intubation (P <0.0001) compared with the Macintosh.

CONCLUSION

In this manikin study, the McCoy demonstrated multiple advantages over the Macintosh. The iLMA was associated with the fastest time to intubation and minimum force of insertion.

Intubating laryngeal mask airway placement by non-physician healthcare providers in management out-of-hospital cardiac arrests: a case series

AIM OF THE STUDY

The role of supralaryngeal devices in airway management in out-of-hospital cardiac arrests (OHCA) remains controversial. The aim of this prospective observational trial was to evaluate the feasibility and effectiveness of intubating laryngeal mask airway (ILMA) when used by trained prehospital emergency nurses in the setting of OHCA.

METHODS

After approval from the Research Ethics Board, prehospital emergency nurses trained in placement of ILMA (Fastrach™, LMA Vitaid, Toronto, Ontario, Canada) followed a formal protocol for airway control during OHCA. The primary outcome was the success rate of ILMA placement, while secondary outcomes were success rate of tracheal intubation through the ILMA, and the incidence of regurgitation of gastric contents.

RESULTS

During the study period, 302 ILMA placements were attempted by emergency nurses during OHCA resuscitation. After ILMA placement, but before attempt for intubation, ventilation was possible in 290 patients (96%). Obstruction or major leaks were observed in 12 patients (4%). Tracheal tube insertion through the ILMA was attempted in 265 patients, and was performed in 254 (95.8%). This allowed for proper lung ventilation through the tracheal tube in 242 cases whereas 12 tubes were esophageal or proved obstructed. Regurgitation of gastric contents occurred in 43 (14.2%) patients; in 23 cases before arrival of the first aid team, in 18 cases before ILMA placement, and in 2 cases after the ILMA placement.

CONCLUSION

The use of ILMA for airway management by trained emergency nurses during OHCA resuscitation is feasible and allows for effective airway management. The success rate of tracheal tube placement through the ILMA was high. In addition, the incidence of regurgitation was lower when using the ILMA than that previous historical reports with face-mask ventilation.

The Fastrach Intubating Laryngeal Mask Airway: an overview and update

PURPOSE

To provide an evidence-based overview and update on the use of the Fastrach Intubating Laryngeal Mask Airway (FT-LMA) when used within operative and non-operative settings.

PRINCIPAL FINDINGS

The FT-LMA is available in three sizes to provide ventilation and the ability to pass an endotracheal tube (ETT) into the trachea blindly, semi-blindly, or with indirect visualization for patients over 30 kg. The Chandy maneuver is recommended routinely; the first maneuver optimizes ventilation, and the second maneuver increases success at endotracheal intubation (ETI). The manufacturer's reinforced tube or a pre-warmed or reversed standard ETT may be utilized. Insertion and ventilation are successful in almost all patients. Blind ETI is highly successful; adjuncts are generally not necessary. The FT-LMA has a proven role in the airway management of anticipated difficult operating room (OR) intubations, unanticipated OR intubations, cervical spine injuries, and limited airway access situations. Literature in the pre-hospital and emergency department settings is limited but favourable. The FT-LMA has compared favourably with fibreoptic intubation, the LMA-Classic, the laryngeal tube, and the CobraPLA. Initially, the more expensive LMA CTrach appeared to be more successful, but overall it is not. The FT-LMA airway seal pressures are excellent; serious complications are uncommon, and the FT-LMA figures prominently in most difficult airway guidelines.

CONCLUSIONS

The FT-LMA has proven to be a useful difficult airway device both within and outside of the operating room. Effective ventilation is established in nearly all cases, and blind ETI is possible in the vast majority of cases if the optimal techniques described are used. Serious complications are uncommon.

Laryngeal tube and intubating laryngeal mask insertion in a manikin by first-responder trainees after a short video-clip demonstration

INTRODUCTION

This study was performed in the Finnish Defense Forces to assess the potential applicability and value of short video clips as educational material to teach advanced airway management and as the first means of introducing the use of a laryngeal tube (LT) or an intubating laryngeal mask (ILMA) to inexperienced, military, first-responder trainees with no prior hands-on experience.

METHODS

The 60 non-commissioned medical officers participating in this study were randomly assigned into one of two groups: the LT- and the ILMA-group. After viewing the video clips, the trainees were required to perform 10 consecutive, successful insertions of the given instrument into a manikin. The number and duration of the attempts required prior to the 10 consecutive successful insertions were measured.

RESULTS

The goal of 10 consecutive successful insertions was attained by all 30 subjects in the LT-group, and by 27 of 29 subjects in the ILMA-group with a maximum of 30 attempts. Improvement in the ease and speed of insertion was evident between the first and last consecutive insertions in both groups.

CONCLUSIONS

"Satisfactory" to "good" skill levels are achieved with the applied video-clip demonstration method, even in inexperienced first-responder trainees lacking previous hands on experience.

Tracheal intubation and alternative airway management devices used by healthcare professionals with different level of pre-existing skills: a manikin study

The classic Laryngeal Mask Airway (cLMA), ProSeal Laryngeal Mask Airway (PLMA), Intubating Laryngeal Mask Airway (ILMA), Combitube (CT), Laryngeal Tube (LT) and tracheal intubation (TI) were compared in a manikin study. Nurses, anaesthetic nurses, paramedics, physicians and anaesthetists inserted the devices three times in a randomised sequence. Time taken for successful insertion, success rates and ease of insertion were evaluated. Anaesthetists performed tracheal intubation significantly faster than other healthcare professionals (p < 0.05). Insertion times for the cLMA, PLMA, LT and CT were not significantly different between the groups. Insertion of the CT, ILMA and TI was associated with a significant learning effect in all groups. This was not observed with the cLMA, PLMA or LT. All non-anaesthetists were able to insert the cLMA, PLMA and LT within two attempts with a > 90% success rate on the first attempt. The ILMA and TI were the only devices where more than one subject experienced some difficulty in insertion. The cLMA, PLMA and LT should be evaluated for use in situations where only limited airway training is possible.

Successful training of HEMS personnel in laryngeal mask airway and intubating laryngeal mask airway placement

INTRODUCTION

To evaluate laryngeal mask airway (LMA) and intubating laryngeal mask airway (ILMA) placement by helicopter emergency medical services (HEMS) personnel after a comprehensive training program.

METHODS

HEMS flight staff attended a didactic and manikin-based training session for both devices. After this training, they attempted LMA and ILMA placement in live, anesthetized patients in an operating room (OR). Outcome measures included placement success rates with the LMA, ILMA, and endotracheal intubation through the ILMA, time to ventilation, and time to intubation. Success rates and time to ventilation were compared using chi-squared and analysis of variance (ANOVA), respectively. Mean time to ventilation for the first and second placements of both devices was examined with repeated measures ANOVA.

RESULTS

There was no difference in successful placement of the LMA compared with the ILMA (100% vs. 91%, P = .15). Ninety-five percent (19/20) of patients were successfully intubated through the ILMA. Time to intubation was 57.1 +/- 55 seconds (range, 20-240). Mean time to ventilation with either device did not differ significantly (36.8 +/- 17 vs. 38.05 +/- 20 seconds; P = .29). Mean time to ventilation for the first and second placement of either the LMA (P = .45) or the ILMA (P = .47) was not statistically different.

CONCLUSION

Trained HEMS flight staff are capable of effectively placing the LMA and ILMA in the operating room after a comprehensive training protocol.

A pilot study of the King LT supralaryngeal airway use in a rural Iowa EMS system

INTRODUCTION

In 2003, the King Laryngeal Tube (LT) received FDA approval for US sales. Prehospital systems in urban setting have begun evaluating and adopting the LT for clinical airway management. However, it is not routinely approved by State EMS Boards for use by all prehospital providers. Given the LT's simple design there may be benefit to using this tool for airway management in all levels of prehospital providers. This pilot study reviews cases where the King LT was used in a rural Iowa county EMS system.

METHODS

In 2006, the Iowa Department of Public Health / Bureau of EMS approved a 12 month pilot evaluating the King LT by all levels of EMS providers in a rural county EMS system. Following a didactic and competency training session on using the King LT, the providers were instructed to continue airway management per usual protocol but were allowed to use the King LT as a first line airway tool if they felt indicated. Successful placement of airway devices used were determined by colourimetric end-tidal CO2, chest auscultation and rise as well as vital sign and skin colour improvement. Review of the data was approved by the University of Iowa Institution Review Board (IRB).

RESULTS

During the 12-month pilot period, the King LT was used in 13 patients with a mean age of 60.7 years (24-81). All patients had cardiopulmonary or traumatic arrest. The King LT was successfully placed on the first attempt in all but one case. The King LT was placed following endotracheal intubation failure in 6/13 (46.1%) cases and in 3/13 (23.1%) of cases of Combitube attempt / failure.

CONCLUSIONS

This small pilot project emphasizes the need for additional rapid airway management tools given the demonstrated ETI failures. The authors believe the King LT has significant potential to impact prehospital airway management as a primary airway device or backup to other failed strategies. Further study is necessary to evaluate the LT's efficacy compared to current strategies.

[The laryngeal tube]

The laryngeal tube (VBM Medizintechnic GmbH, Sulz, Germany) is a supraglottic device designed for airway management in spontaneous or positive-pressure ventilation during anesthesia or in cardiopulmonary resuscitation. Currently, the tube is available in 4 versions: the standard laryngeal tube, the disposable tube (LT-D), the dual-lumen tube (with a tube for suction) (LTS II), and the disposable LTS (LTS-D). The design of the tube has been modified several times. It is easy to insert and the airway seal is more effective than that of the laryngeal mask. The incidence of complications is similar for both devices, though use of the laryngeal tube requires more adjustments. The standard tube is somewhat less effective than the ProSeal laryngeal mask, though the new LTS II has been improved considerably. The laryngeal tube is effective as an aid to management of the difficult airway. We reviewed the literature indexed on MEDLINE through December 2006 using the search terms laryngeal tube, anesthesia, equipment, and airway.

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.

Tracheal intubation using the ILMA, C-TrachTM or McCoy laryngoscope in patients with simulated cervical spine injury

A study of 90 patients was undertaken to compare intubation success rates of using either ILMA, C-Trach or McCoy laryngoscope in patients with simulated cervical spine injury. Insertion and intubation success rates, time taken to achieve intubation, airway complications and haemodynamic parameters were recorded. Insertion of ILMA and C-Trach was successful at the first attempt in all patients. Intubation success rates were higher in the C-Trach (100%) and McCoy (100%) groups than in the ILMA (87%) group. Total intubation time was significantly longer in the ILMA (63 s, SD 36.5) group than in the C-Trach (41 s, SD 15.8) and McCoy (30 s, SD 7.4) groups (p < 0.05, p < 0.05, respectively). There were no significant differences in haemodynamic parameters among the groups at any time.

Vergleich zwischen Larynxtubus-S und endotrachealer Intubation

BACKGROUND

The value of the laryngeal tube S (LTS) for emergency airway management was evaluated in comparison to endotracheal intubation (ETI).

METHODS

Physicians were asked to perform simulated airway management in an airway mannequin. The physicians were allocated into three groups according to their experience in intubation (1: <50, 2: >50, 3: >500 intubations). The success rate using LTS and ETI, the time needed for securing the airway, and the rating of both techniques by the participants were recorded.

RESULTS

A correct position was achieved with the LTS in 99.39% of attempts (n=325), and with the endotracheal tube in 92.35% (n=302). Using the LTS it took an average time of 10.85 s to achieve the first successful ventilation, as compared to 17.75 s in ETI (p<0.0001). Participants from group 1 needed longer to achieve ETI in the 2nd (18.4 s vs. 16.4 s, p<0.0001) and 3rd attempts (16.9 s vs. 15.8 s, p<0.0001) compared to those from group 3.

CONCLUSIONS

The LTS represents a fast and reliable method to secure the airway and to achieve ventilation in the mannequin model described. The success rate, the time until successful ventilation and the rating by the participants indicates that the LTS is an important alternative to ETI. The LTS offers special benefits for the less experienced users.

The laryngeal tube

The laryngeal tube (VBM Medizintechnik, Sulz, Germany) is a relatively new extraglottic airway, designed to secure a patent airway during either spontaneous breathing or controlled ventilation. In this review article, we have assessed the potential role of the laryngeal tube during anaesthesia and during cardiopulmonary resuscitation. There are four variations of the laryngeal tube: standard laryngeal tube, disposable laryngeal tube, laryngeal tube-Suction II and disposable laryngeal tube-Suction II. The design of the device has been revised several times. Insertion of the standard laryngeal tube is as easy as with the laryngeal mask airway classic. The laryngeal tube may provide a better sealing effect than the laryngeal mask. The incidence of complications with the two devices is similar, although the laryngeal tube may require more re-adjustments of its position to obtain a clear airway. Compared with the ProSeal laryngeal mask, the laryngeal tube may be less effective. The efficacy of the standard laryngeal tube is unclear, particularly in patients breathing spontaneously or in children. The efficacy of the laryngeal tube Suction-II and disposable devices is also not clear. From the limited number of studies and reports available, it can be concluded that the laryngeal tube is potentially useful in maintaining a clear airway during anaesthesia and cardiopulmonary resuscitation. In addition, the device may be useful as an aid to tracheal intubation.