Airway management and the subsequent provision of oxygenation and ventilation remains one of the foundational principles in the clinical practice of Emergency Medicine in the Emergency Department and the prehospital environment. The majority of advanced airway interventions in the prehospital environment occur in the cardiac arrest or major trauma patient with significant altered mentation. A growing body of evidence questions actual survival benefit for the practice of endotracheal (ET) intubation. A baseline proficiency in airway management via intubation requires on the order of 50 to 100 intubations, a clinical experience not commonly found in the prehospital training environment.1 Even more disheartening are numerous studies demonstrating a significant percentage of cases of unrecognized esophageal airway placement or ET tube migration out of the airway upon Emergency Department arrival. Such therapeutic misadventures guarantee bad outcomes.2 Most of these studies describe relatively busy prehospital systems with clearly defined medical oversight.
Evidence-based cardiopulmonary resuscitation (CPR) science has shown that limiting “no-flow time” associated with compression-ventilation cycles is directly related to the efficiency of resuscitation as measured by coronary perfusion pressure. Most supraglottic airway devices (SADs) can be placed with a very high first-pass success rate in under 20 seconds. This allows for progression to continuous uninterrupted compression cycles with interposed ventilations. Multiple prehospital systems have placed SADs into their protocols for the use of alternative airway devices in preference over ET intubation.3,4
The spectrum of airway management begins with the Basic Life Support (BLS) skill set using airway positioning, suctioning, and ventilation support with the use of a bag-valve-mask device. The next decision is to progress to the Advanced Life Support (ALS) skill set for definitive long-term airway management via cuffed ET tube placement or a surgical airway. ALS management has revolved around the concept of placing a cuffed ET tube. The concept of the “rescue airway device” has risen as a back-up technique after unsuccessful ET tube placement using a SAD as a conduit for oxygenation and ventilation to “buy some time.” This life-saving practice is included in difficult airway and CPR algorithms aimed at maximizing uninterrupted chest compressions.5-11 It is a reasonable expectation that the Emergency Physician develop a baseline expertise and experience with a variety of SADs. This is for receiving patients who have had them placed and when ALS procedures do not go exactly as planned in the Emergency Department.
The original creation of SADs as airway adjuncts occurred with an initial aim at the operative airway management of patients in the Operating Room. Simplistically, SADs function as a conduit between the mouth and laryngeal inlet at the vocal cords, bypassing tongue-induced airway obstruction in the sedated and paralyzed patient during an operation.12 The classic laryngeal mask airway (cLMA) is the original example of a SAD. It was created in 1981 and is used daily in Operating Rooms across the world with several hundred million ...