Airway management remains one of the cornerstones of the clinical practice of Emergency Medicine in both the Emergency Department and the prehospital environment. The majority of advanced airway placements in the prehospital environment occur in the cardiac arrest or trauma patient. Advances in the science of performing better cardiopulmonary resuscitation (CPR) aim to limit the “no-flow-time” associated with resuscitation. Most supraglottic airway devices aim for an insertion time under 30 seconds. Some Emergency Medical Service (EMS) systems have emphasized the use of an alternative airway device over endotracheal intubation.1,2
In the overall performance of airway management, the provider often begins with the basic life support (BLS) skill subset such as airway positioning, suctioning, and assisting spontaneous respirations with the use of a bag-valve-mask (BVM) device. They then jump to the advanced life support (ALS) skill subset such as placement of cuffed endotracheal tubes and surgical airway management. Traditional ALS management has revolved around the concept of placing an endotracheal tube. Over time, this has rolled out to the prehospital environment of care and is now firmly established into the current scope of practice for EMS professionals. The literature remains controversial and divided, with multiple recent studies suggesting limited benefit of prehospital endotracheal intubation in a variety of clinical settings. Even more disheartening are numerous studies demonstrating a significant percentage of unrecognized esophageal airway placement or endotracheal tube migration out of the airway upon Emergency Department arrival. Such therapeutic misadventures guarantee bad outcomes.3 Most of these studies describe relatively busy EMS systems with clearly defined medical oversight. With inexperienced hands, the success rate is lower and the complications rates are high, and aggressive airway management has been linked to a decreased odds ratio for patient survival. In between BLS and ALS lies a very large grey area, with many airway adjuncts available to help with airway management.
The creation of a wide variety of airway adjuncts termed “supraglottic airway devices” (SADs) has occurred in order to facilitate airway management. Simplistically, SADs function as a bridge between the mouth and the vocal cords, allowing for air movements while bypassing tongue-induced airway obstruction.4 Some recommended the term “extraglottic” to replace supraglottic in order to better define the relationship between function and not define anatomic position. For the purposes of this chapter, the two terms will be considered synonymous.
The classic laryngeal mask airway (LMA) is a common example of a SAD. It is utilized daily in operating room cases with a cumulative record of over 200 million episodes of use in patient care.4,5 Most Emergency Physicians in training will get some exposure to the use of SADs as a result.5 Not surprisingly, the logical migration of airway devices from the operating room to the prehospital and Emergency Department environments has also begun. Each SAD comes with manufacturing claims as to their device superiority over the competition in a very competitive marketplace. It ...