Clinical paperRisk factors for unsuccessful prehospital laryngeal tube placement☆
Introduction
Performance of airway management is a complex aspect of prehospital care. Orotracheal intubation has long been the standard of practice for prehospital advanced life support providers, but concerns over low success rates and unidentified esophageal intubation have called this practice into question.1, 2, 3 Supraglottic airway devices (SGAs) have received widespread acceptance and use in the in-hospital and prehospital settings, both as a rescue device after unsuccessful orotracheal intubation and as a primary airway device.4, 5, 6, 7, 8, 9, 10, 11 SGAs have been used widely in out-of-hospital cardiac arrest, and also as part of rapid sequence airway placement.4, 9, 12, 13, 14
The King Laryngeal Tube (King LT, King Systems, Nobleville, IN) has won broad acceptance in the prehospital setting due to ease of use, including a single inflation port.4 In contrast to other available SGA devices, the King LT was primarily designed for emergency and prehospital use,15 and studies of its use in mannequins by Emergency Medical Services (EMS) providers have demonstrated high procedural success rates in these simulated models.16, 17, 18, 19 Similarly, early reports of its use in patients in the operating room identified high airway placement success rates of 86–100%.20, 21 However, subsequent studies of King LT use in the prehospital setting, limited by sample size or LT use as part of a study protocol, revealed wide variability in first attempt success rates of 68–97%.7, 8, 9, 10, 22 Additionally, there are no studies characterizing factors associated with unsuccessful laryngeal tube placement.
We aimed to identify factors that were associated with unsuccessful prehospital laryngeal tube placement. We further aimed to describe the first attempt success rate of laryngeal tube airway placement by both ground advanced life support and air critical care EMS agencies using established prehospital airway management protocols, and describe the final airway management strategy provided in these cases.
Section snippets
Study setting and population
We performed a retrospective review of all cases with attempted laryngeal tube placement by paramedics and prehospital nurses in 36 EMS agencies that receive medical oversight from the University of Pittsburgh Medical Center. This included 35 ground Advanced Life Support (ALS) EMS agencies in Southwestern Pennsylvania (“ground”), as well as STAT MedEvac, a multi-state air critical care transport agency with 17 base sites staffed by critical care paramedics and nurses (“air”). All of these
Results
We identified 481 patients who received 511 attempts at laryngeal tube placement. We excluded 4 patient cases in which a physician placed the laryngeal tube (all successful in the first attempt), leaving 477 cases (156 air, 321 ground) of first-attempt laryngeal tube placement by paramedics and prehospital nurses, which formed the study cohort (Fig. 1). King LT placement occurred as a primary airway (no prior intubation attempt) in 99 (20.8%) cases and as a rescue airway in 378 (79.2%) cases,
Discussion
We identified factors associated with unsuccessful laryngeal tube placement in a large cohort of prehospital patients managed by 35 ground ALS services and a multi-state air medical critical care service. Male gender, ground (versus air) agency, and presence of a gag reflex were associated with unsuccessful laryngeal tube placement. These results highlight the complexities of LT placement in the prehospital setting, and shed light on occasional failures, potential reasons for failures, and the
Conclusions
We identified that the laryngeal tube is an effective airway management tool for both ground advanced life support and air critical care prehospital providers with a first pass success rate of 84.9%. Predictors of unsuccessful placement were male gender, ground ALS agency, and presence of a gag reflex. This information may help refine prehospital airway management algorithms.
Conflict of interest statement
None of the authors have any relevant conflicts.
Funding sources
None.
References (27)
Which airway for cardiac arrest? Do supraglottic airways devices have a role?
Resuscitation
(2013)- et al.
Comparison of prehospital insertion success rates and time to insertion between standard endotracheal intubation and a supraglottic airway
Resuscitation
(2011) - et al.
Supraglottic airway device use as a primary airway during rapid sequence intubation
Air Med J
(2013) - et al.
King LT-D use by urban basic life support first responders as the primary airway device for out-of-hospital cardiac arrest
Resuscitation
(2011) - et al.
Endotracheal intubation versus supraglottic airway insertion in out-of-hospital cardiac arrest
Resuscitation
(2012) - et al.
Rapid sequence airway vs rapid sequence intubation in a simulated trauma airway by flight crew
Resuscitation
(2010) - et al.
Supraglottic airway devices
Best Pract Res Clin Anaesthesiol
(2005) - et al.
The laryngeal tube: a new adjunct for airway management
Prehosp Emerg Care
(2000) - et al.
The use of the laryngeal tube disposable (LT-D) by paramedics during out-of-hospital resuscitation-an observational study concerning ERC guidelines 2005
Resuscitation
(2009) - et al.
Simulated rescue airway use by laypersons with scripted telephonic instruction
Resuscitation
(2009)
A meta-analysis of prehospital airway control techniques. Part I. Orotracheal and nasotracheal intubation success rates
Prehosp Emerg Care
Paramedic intubation errors: isolated events or symptoms of larger problems?
Health Aff (Millwood)
A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region
Prehosp Emerg Care
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.10.015.