Alternatives are essential in airway management
New devices like the laryngeal mask airway and Combitube may rarely be used in the ED setting, but physicians need as many options as possible when it means the difference between life and death
When faced with a difficult airway, emergency physicians should have as many options as possible at their fingertips. "Nowhere does the "one size does not fit all" maxim apply more than in airway management. "There is no single best way for every possible circumstance," says Ron Walls, MD, FACEP, FRCPC, chairman of the department of emergency medicine at Brigham and Women’s Hospital and associate professor of medicine in the division of emergency medicine at Harvard Medical School in Boston. "Airway management is the single most important defining skill of emergency physicians, so it’s extremely important for us to be up to date."
Laryngeal mask airways (LMAs) show promise as a conduit for tracheal intubation, he says. "We have established the LMA as an essential part of our difficult airway management," Walls notes. "It’s not the airway method of choice, but it’s one of a number of devices we use as a rescue airway device."Although used infrequently in the ED, LMAs are an essential aspect of airway management. "If you’re in that desperate situation where the only other option is death, you are looking for a rescue device," says Michael Murphy, MD, FRCPC, executive director of emergency health services for the province of Nova Scotia in Canada, and associate professor of emergency medicine at Dalhousie University in Halifax, Nova Scotia. "You might only use the LMA once or twice or year, but you’re glad it’s there when you need it."
At Dalhousie’s ED, an airway management tray contains airway rescue devices, including LMAs, Combitubes, and cricothyrotomy sets. "If you’ve got a patient that you can’t intubate and can’t ventilate, especially a paralyzed patient, you may use an LMA or a Combitube as a rescue device, as a temporizing maneuver," Murphy explains. "If you’re going to put yourself in a situation where you have a paralyzed patient that you can’t ventilate, you better have a way out."
"There are only two devices we use in the can’t intubate, can’t ventilate’ situationLMAs and Combitubes," says Murphy. "The advantage of the LMA tube is that you can intubate through it, but the downside is that the patient remains at risk for aspiration," notes Murphy. "I don’t think it’s a semi-elective airway management tool in emergency medicine at all."
Surgical airways are always another possibility. "You can always do a surgical airway, but the reluctance and skill required to do it probably militates against it. People will more often than not choose a nonsurgical technique like an LMA," says Murphy.
LMAs have very limited use in the ED. "Most of our airways are handled by rapid sequence intubation and placement of the endotracheal tube. But in the algorithm for alternative airway devices, if we have difficulty placing the tube or oxygenating the patient with the bag valve mask, and we know that we don’t have any supraglottic obstruction, then I think the LMA or the Combitube would be an appropriate choice as a temporizing maneuver for oxygenation and ventilation of the patient," says Robert Schneider, MD, FACS, FACEP, residency director of the department of emergency medicine at the Carolinas Medical Center in Charlotte, NC.
ED staff should be familiar with the use of the LMA, he says. The ED’s first-year residents use the device frequently during their anesthesia rotations, although the opportunities to use it in the ED are limited. "From that point on, it’s a matter of them taking the opportunity to practice with it in the ED," says Schneider.
At Dalhousie, difficult airway management training is done every year, including LMAs. "Not everyone has used it, but they’re all familiar with it," says Murphy.
Another area where LMAs are used is prehospital care. "It can be helpful for those people who aren’t paralyzing patients, or in areas where they have trouble intubating somebody and don’t want to do a surgical airway on them," says Schneider. "We are very fortunate that the vast majority of patients we have to intubate we can get the tube in, but if you’re in the prehospital area where you don’t have any backup or the necessary expertise, LMA or Combitubes are a definite consideration."
For pediatric patients, however, Combitubes are not available. "Their smallest size is for a patient who’s about five feet tall, so it’s just not an option for smaller kids," says Robert Luten, MD, FACEP, FAAP, professor of pediatric emergency medicine at University of Florida in Jacksonville. "If you want that type of alternative, it would have to be an LMA. However, you’re less likely to run into a situation where you need it, because most kids can be bagged fairly effectively."
Still, when needed, the LMA has the potential to work well when used in pediatric patients. "The LMA has been used traditionally in patients with high anterior airways so you can’t visualize very well, when you look with the laryngoscope, and small kids, especially infants, all have high anterior airways, so at least theoretically it should work fairly well in that situation," says Luten.
ED physicians should choose their airway devices carefully, says Murphy. "There are a lot of airway devices, but when you put a plethora of devices in front of an emergency physician who doesn’t use them every day, it becomes difficult to select," he explains. "You should try to limit your selection to devices that are easy to teach and easy to use. What you want is as many tools as you can remain familiar with."
Other applications for LMA use in the ED are on the horizon. An intubating LMA-Fastrach will be introduced by early 1998. "It’s possible that the new LMA-Fastrach might be used deliberately as an intubating guide in airway management," says Walls. "We need a better understanding of how it could be used in emergency medicine other than as a simple rescue device. There is a significant potential role for it."
Twenty centers around the country are currently tracking the use of airway devices as part of NEAR97 (National Emergency Airway Registry), of which Walls is principal investigator. All ED intubations are prospectively tracked by these research centers, including methods used, success rates, and rescue devices. "We see potential for this registry to function as the premier system for airway research in the United States and Canada," Walls notes.
[Editor’s Note: Laryngeal mask airways are available from Gensia Automedics Inc., 9360 Towne Centre Drive, San Diego, CA 92121. The reusable LMA-Classic is $220, and the single-use LMA-Unique is $36. Instructional videos and manuals are available free of charge. For more information, call (800) 788-7999 or fax (619) 622-5552. Doctors Walls, Schneider, Murphy, and Luten have developed a national emergency airway course, an intensive two-day hands-on workshop that focuses exclusively on ED airway management; including rapid sequence intubation, surgical airway management, rescue devises such as the LMA, Combitubes, lightwand, and special approaches to the difficult airway and pediatric airways. The course will be offered up to eight times in four cities in 1998. For a course brochure, contact Dr. Ron Walls by e-mail at [email protected] or by telephone at (617) 732-5989.]
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