Removing an LMA and performing intubation

[DocBrock]

Theres a lot of very closed minded views on airway treatments but I wanted to see what this brings.
Let's say you have a critical Pt. Your EMT partner successfully places an IGEL as you perform ALS care and stabilize the pt. Once all other life saving treatments have been initiated, you slide up to the airway, remove the IGEL and successfully intubate. And if the intubation is unsuccessful I would reinsert the igel and leave it.

Is there anyone out there with a positive view on this or advice that isn't one of these typical responses?

"If the BLS airway works leave it" "BLS before ALS" "Why take the risk of not having an airway if the intubation fails" "You're dumb and over treating" "very few times is intubation any better"

I personally would like a ETT tube used to ventilate me, I'd like my airway protected. If my belly fills with air and causes increased thoracic pressure causing decreased cardiac output, I'll be upset that no one tried to eliminate that possibility by attempting intubation. Lets hear some talk.

 

[VentMonkey]

If the I-gel, or any supraglottic airway has been placed prior to our arrival, appears to be working well, yields a good ETCO2 reading, and the patient appears to have adequate compliance (good chest rise and fall, and is being ventilated without issues) I see no reason to remove the device in the prehospital setting.

There's a lot more that goes into advanced endotracheal intubation that just the skill itself. I personally would want the most experienced provider with "first pass" success rate, followed by the proper procedures that come with airway management after the skill itself has been performed, and even before. This includes proper BLS management, good ventilation technique, and having any blind airway adjuncts prepped and ready to go in the event that the airway becomes a difficult one.

Also, I did make mention of this in another thread, and while there seems to be mixed opinions on it, an NG/OG tube does wonders to prevent/ rectify gastric distension; and it's kind of a given in the hospital setting anyhow.

 

[DocBrock]

Well wrote. On the discussion of NG/OG, if this is being considered on a supraglottic airway I guess a pt being Bag valve masked would be even more of a candidate for a gastric tube? Any personal complications with mask seal with gastric suction? I find gastric inflation very common often after 10 plus minutes of ventilation, even when using pediatric bags on adults and good technique (currently in our protocol for Pts being BVM for more than 5 minutes)

 

[VentMonkey]

Well wrote. On the discussion of NG/OG, if this is being considered on a supraglottic airway I guess a pt being Bag valve masked would be even more of a candidate for a gastric tube? Any personal complications with mask seal with gastric suction? I find gastric inflation very common often after 10 plus minutes of ventilation, even when using pediatric bags on adults and good technique (currently in our protocol for Pts being BVM for more than 5 minutes)

Any patient receiving BVM ventilations will eventually need an advanced airway, be it a blind airway such as an I-gel, or in my neck of the woods a King, or an ET tube. Some King's do permit gastric tubes to be placed through them. I don't believe ours do, but again, chances are if the patient we are bringing in to the ER is a viable one with a blind airway in, they'll remove it and place an ET tube, and/ or place a gastric tube in them.

Yes, gastric insufflation is an issue, and pertinent that we manage (eventually), but hypoxia is a true killer, and needs to be remedied post haste. So focus on proper oxygenation, and ventilation techniques prior to ED arrival, which would play more into the patients outcome long term more than a potential for aspiration.

If you're that concerned about it, simply placing the patients head at a 30-45 degree angle while you properly ventilate them on the way to the hospital can be a remarkably undervalued technique that may further insufflation/ prohibit further aspiration.

In summary, gastric distension is a secondary complication when dealing with, and securing a patients airway.

 

[Carlos Danger]

If the SGA is working well, leave it. You gain little by removing a working airway and exposing the patient to the risks of intubation.

As far as gastric tubes in the field, I don't think there is any literature that supports their use routinely.

 

[Nova1300]

Are we speaking only of cardiac arrest?

Because outside of cardiac arrest, a supraglottic airway should be a rescue device, not a primary therapy.

 

[NomadicMedic]

Are we speaking only of cardiac arrest?

Because outside of cardiac arrest, a supraglottic airway should be a rescue device, not a primary therapy.

Why? If it's indicated and works, why not?

I recently had an unresponsive CVA patient that needed airway management. No neck, small mouth, extremely obese. That patient got a king. First line, not rescue.

 

[DocBrock]

Why? If it's indicated and works, why not?

I recently had an unresponsive CVA patient that needed airway management. No neck, small mouth, extremely obese. That patient got a king. First line, not rescue.

But why? What's the deal with paramedics not providing advanced airways to our patients just because a BLS airway is "working" The ED is going to place a ET tube the moment you get in there so why not just do it right the first time. "There's only 2 ways to do things, the right way, or again"

 

[VentMonkey]

Are we speaking only of cardiac arrest?

Because outside of cardiac arrest, a supraglottic airway should be a rescue device, not a primary therapy.

Perhaps you are referring to patients who would be candidates for RSI?

Patients who are selected to be induced with a sedative, and paralytic should have a "rescue device" close at hand, absolutely, however DEmedic makes a valid point and uses a good example of when and where to know our limitations field providers.

To me it shows excellent judgement, and critical thinking skills. I also think it's an important point to make for new clinicians at all levels to understand that not every patient in the field will be intubated, which can be for a number of reasons.

 

[VentMonkey]

But why? What's the deal with paramedics not providing advanced airways to our patients just because a BLS airway is "working" The ED is going to place a ET tube the moment you get in there so why not just do it right the first time. "There's only 2 ways to do things, the right way, or again"

A King or other supraglottic airway devices is considered advanced airways to some.

I work in a system that ranges from a densely populated metropolitan response area, to very rural where flying them out provides significant times savings.

Here's another example, and hopefully it makes a little more sense as to why a paramedic wouldn't just remove a King airway to intubate. If we landed at a scene, and the patient was found unresponsive, with a pulse, and the device is working well then there is no reason to remove it to attempt intubations (which may fail, and cause the initial airway device to be reinserted) and further expose the patient to things such as prolonged hypoxia (again, the true killer here), and aspiration.

Again, if the BLS airway is a simple BVM, then sure there's nothing wrong with giving it the old college try, however, if by just looking at the patient, the provider knows that they would be a difficult airway and they chose to go to another device aside from endotracheal intubation, I am not removing it on scene, or in flight just to say I intubated.

If ain't broke, don't fix it. I hope this sorta clarifies some of what is being said here. Also, when you get a sec, look up Ron Walls. His book will lay it all out for ya.

 

[cprted]

I don't think there is a black and white answer to this: There are two many variables in play. In my own experience (total about 30 minutes, give or take ... lol), there have been cases where I've left a supraglotic in place and others where I've removed it. Just depends on the circumstances.

I think there should be a lot of weight placed on the, "if it isn't broke, don't fix it" rationale though. What is our end goal of airway management? Effective gas exchange. If a supraglotic is achieving that goal, it seems counterintuitive to arbitrarily remove the SGA in favour of intubation.

I also don't put a lot of stock in the argument that, 'well, they're going to intubate as soon as we get them to the ED anyway.' So what? Risk stratifying a field intubation is completely different than what goes on in hospital. The resources available to an EP in a hospital (especially if we're talking L1 or L2 Trauma Centre) is profoundly different to what we have at our disposal in the field.

 

[NomadicMedic]

But why? What's the deal with paramedics not providing advanced airways to our patients just because a BLS airway is "working" The ED is going to place a ET tube the moment you get in there so why not just do it right the first time. "There's only 2 ways to do things, the right way, or again"

I don't define airways by BLS or ALS. I use critical thinking to figure out what's going to work and then I use that tool. In this case, a preintubation assessment showed that my patient might have been a difficult intubation and because I am currently at a service where I don't have any other trained hands to help, no VL, no RSI and I have the knowledge that things might have gone badly if I decided to stuff a layrngoscope blade in her mouth, I elected to use a King to manage the airway.

Everyone practices differently.

 

[VentMonkey]

Hopefully the op hasn't been scared away from his own thread, lol.

This is some good insight from folks who appear to have sound clinical judgement on when one would, or wouldn't intubate, and why.

DocBrock, as you can see this can be a very touchy subject with good reason, and is constantly brought up.

My personal opinion is that a sound clinician never stops learning, and takes initiative with an open mind as to why it is those who have been practicing prehospital medicine (effectively) for sometime do what they do.

As cprted mentioned we are aiming for effective gas exchange. This can be done a number of ways properly, and with each calls brings a new, or different challenge. Learning how to adapt and overcome the obstacles faced on each call, and safely and effectively manage these patients should be the main objective, not "tubing 'em cuz I can".

 

[NomadicMedic]

I personally would like a ETT tube used to ventilate me, I'd like my airway protected. If my belly fills with air and causes increased thoracic pressure causing decreased cardiac output, I'll be upset that no one tried to eliminate that possibility by attempting intubation. Lets hear some talk.

I didn't see this until now, but this is a very interesting quote.

Would you like to have that ET placed by a provider who has very little experience in airway management? Maye placed by a medic who hasn't tubed anyone in a year or two and has most of their intubations on Fred the Head or Sim Man? Or, would you rather have an SGA placed quickly and without error and be ventilated?

 

[Handsome Robb]

I'd have to have a pretty good reason to pull a working SGA to exchange it for an ETT. I'd probably try a bougie exchange of I did decide to do it.

I know vomiting and aspiration is a risk but seeing as most SGAs have a port for OG tube placement these days it kinda becomes a moot point.

Ultimately in the scenario presented I would've directed my partner to use a BVM and basic adjuncts rather than place an airway but I'm also finicky about my patient's airway and the placement of them. Not sure why a Paramedic would be doinking around with other things and leaving the airway for later unless it's a cardiac arrest but I digress.

In DE's scenario I think that displays good judgement. If you don't have tools available to you like VL and you anticipate a very difficult airway I'd probably, and have in the past, use a SGA over ETT. Now that I have VL most everyone gets intubated though and the iGel is used as a rescue.


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[VentMonkey]

I'd have to have a pretty good reason to pull a working SGA to exchange it for an ETT. I'd probably try a bougie exchange of I did decide to do it.

I know vomiting and aspiration is a risk but seeing as most SGAs have a port for OG tube placement these days it kinda becomes a moot point.

Ultimately in the scenario presented I would've directed my partner to use a BVM and basic adjuncts rather than place an airway but I'm also finicky about my patient's airway and the placement of them. Not sure why a Paramedic would be doinking around with other things and leaving the airway for later unless it's a cardiac arrest but I digress.

In DE's scenario I think that displays good judgement. If you don't have tools available to you like VL and you anticipate a very difficult airway I'd probably, and have in the past, use a SGA over ETT. Now that I have VL most everyone gets intubated though and the iGel is used as a rescue.


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How do you like the iGel? Does it work as well as say, the King can?

I do believe SGA's have come a long way from the days of the EOA, and are slowly being accepted into the prehospital arena by even the crustiest of old skool paramedics.

 

[Carlos Danger]

But why? What's the deal with paramedics not providing advanced airways to our patients just because a BLS airway is "working" The ED is going to place a ET tube the moment you get in there so why not just do it right the first time. "There's only 2 ways to do things, the right way, or again"

Well, there's your problem right there. You seem to misunderstand the fundamentals of the issue.

First, there is no "BLS airway" or "ALS airway". There are airways that work, and airways that don't. Second, it turns out that there actually is more than one correct way to manage an airway. An ETT is not always the best option, even if it is the most "secure" airway.

I think there should be a lot of weight placed on the, "if it isn't broke, don't fix it" rationale though. What is our end goal of airway management? Effective gas exchange. If a supraglotic is achieving that goal, it seems counterintuitive to arbitrarily remove the SGA in favour of intubation.

This pretty much sums up the whole discussion.

Sure, there are times when replacing the SGA might be indicated. But more often than not, I do not believe it is, especially by the majority of paramedics, who have little experience with airway management. Show me some research that indicates that prehospital intubation is beneficial, and I'll change my position.

I also don't put a lot of stock in the argument that, 'well, they're going to intubate as soon as we get them to the ED anyway.' So what? Risk stratifying a field intubation is completely different than what goes on in hospital. The resources available to an EP in a hospital (especially if we're talking L1 or L2 Trauma Centre) is profoundly different to what we have at our disposal in the field.

Not to mention that even if you took away all the resources that a hospital offers, an emergency physician is simply more experienced and more skilled in airway management in the first place, than most paramedics.

I didn't see this until now, but this is a very interesting quote.
Would you like to have that ET placed by a provider who has very little experience in airway management? Maye placed by a medic who hasn't tubed anyone in a year or two and has most of their intubations on Fred the Head or Sim Man? Or, would you rather have an SGA placed quickly and without error and be ventilated?

You took the words right out of my mouth!

 

[SeeNoMore]

I've been in this situation (always arriving at a scene call) and handled it different ways, either by leaving the device in or utilizing RSI to place an endotracheal tube. Sometimes the decision seemed clear to me : for example arriving to find a poorly placed King Airway with a poor sat. We bagged and placed an ETT. Another time there was a severely traumatically injured patient with a King Airway working well after multiple failed attempts by the ground providers. We opted to leave it in place and expedite transport to the Trauma Center.

To be honest other times we have discussed the options and intubated , and I don't know if we did this just because that is what we are used to. Perhaps we were letting our egos get in the way of the end goal. Good discussion.

 

[Nova1300]

Why? If it's indicated and works, why not?

I recently had an unresponsive CVA patient that needed airway management. No neck, small mouth, extremely obese. That patient got a king. First line, not rescue.

So that patient is a rarity, in my experience. I don't imagine most patients with a GCS above 3 tolerate a supraglottic airway terribly well. Patients who are able will cough, gag and buck on supraglottic airways. When used as a rescue therapy, the patient will most likely have received muscle relaxant, facilitating easy placement of the supraglottic device. If you use as primary management device, you don't have that benefit which certainly increases risk of malposition or dislodging if patients move or fight due to a change in clinical status.

The fact that your patient had a CVA is a great point. Many of our non-cardiac arrest intubations are in brain injured patients who cannot protect their airway. Muscle relaxant will have the added benefit of keeping these patients from coughing and bucking, which would most certainly affect intracranial dynamics.

Brain injured patients are also at very high risk for aspiration because brain injury tends to be so pro-emetic. There is no hard and fast data in that population, however my hunch is that balloon may actually have some demonstrable benefit for these folks.

I understand the worry about a difficult airway. However, my own inclination would be to paralyze and attempt to intubate. If you can't, place the supraglottic device while the patient is asleep and paralyzed which is just about the most effective way to place it in the first place.

If the patient truly is a GCS 3 and has no airway reflexes so that they will tolerate the SGA, the ball is in your court. However, I will tell you that patient with a brain injury who aspirates usually has a pretty rough road for a few days.

To clarify, I do agree with those that say if the airway is in place and working, leave it. My comments are addressing elective use of a supraglottic airway without attempting intubation. Outside of cardiac arrest.

 

[NomadicMedic]

Agreed. An RSI certainly would have been the right thing in this case, but as I mentioned, no RSI or any pharmaceutical assistance, no VL and no help if things went pear shaped. In this case, a King was the right choice.