Monday, June 1, 2015

Guest Post: Supraglottic Airway Devices Should Be Your First Line

This is a guest post written by Jeff Poland, NRP, FAWMc, FACPMc, for the Great EMS What-If-We’re-Wrong-A-Thon. I have a lot of experience in prehospital and perioperative airway management, and on every other day of the year am a stark proponent of the use of supraglottic airway devices only as a rescue airway in emergency situations – almost (around 99.9999999999999% of the time) never as a first line. But, below outlines the best reasoning I can come up with for why:

Supraglottic Airway Devices Should Be Your First Line

While endotracheal intubation has long been touted as the gold standard for airway securement, increasingly we are seeing more and more services and geographic areas move away from endotracheal intubation (ETI) in favour of first line placement of a supraglottic airway (SGA), with the option of ETI if the SGA fails. This is a prudent and much-needed step in the right direction for the following reasons:

Several studies [1,2] have indicated that prehospital intubation has a very low success rate. Intubation is a skill which requires a great deal of practice, and has no correlation with the experience that a paramedic has [3]. In other words, if you don’t do the skill a lot, you aren’t very good at it, and I think that is something that we all can agree on. With most of fire-based EMS, and a lot of third service EMS, focusing on a 5:1 paramedic:patient ratio [4], and the already low frequency of patients requiring this delicate procedure, which, if it fails, is catastrophic for the patient, most paramedics, especially in those systems, simply do not get the required amount of practice to remain proficient.

One of the main concerns regarding airway management is that the airway needs to work. SGAs are dislodged only minimally, and rarely are placed wrong [5]. When your patient needs an airway now, you should just put in a SGA and not have to worry about it any more. An old co-worker of mine once told me “why would I use an ET tube when this (the King Airway) is easier, quicker, and I absolutely know it’s in?” High-stress situations such as cardiac arrest and unconscious/unresponsive patients often have providers anxiety levels up, and an unrecognized oesophageal intubation is almost universally lethal. On the other hand, I have had one endotracheal intubation using a King Airway, and that required 45 minutes, a low profile MAC 3, an airway manikin, and a set of long Magill forceps. (Beth Lattone, of the Community College of Aurora’s Paramedic Program, if you’re reading this, this definitely was not on one of your airway heads, so I don’t even know why I brought it up.)

Supraglottic airways have also been shown to provide some measure of protection against vomiting [6]. This has been shown to be similar to that provided by cricoid pressure, a recognized mainstay in every emergency and failed airway algorithm, although it is much easier to use an SGA than it is to use cricoid pressure. Given that they can protect the airway up to 120cmH2O of pressure, tell me again how ETI is the gold standard?

Furthermore, the King LT has been shown to be equal to ETI in cardiac arrest, and the authors also claim that because of the more rapid airway control, it could be considered superior [7]. Instead of mucking around with trying to get a good laryngoscopic view during cardiac arrest, why not just pop in the SGA and not have to worry about it later on?

ETI is an old skill. Technology is increasing, and making things both better and easier for the provider. Why are some people so focused on keeping the old technology and refusing to adapt to the changing world? So many physicians have gone on record saying that they don’t support paramedics intubating, we continue to have abysmally high failure (and worse, unrecognized oesophageal intubation) rates, and those are time and cost consuming to fix. More and more paramedic programs are getting away with 5 simulated intubations, period, in order to pass, and it sounds like we are rapidly recognizing that ETI in the prehospital setting needs to go the way of the dodo. Even anaesthesiologists are using more and more SGAs for more and more cases. Isn’t it about time we get on board with these changes, and leave ETI for the docs who want to stay outdated?

While those are some compelling arguments against endotracheal intubation, I still firmly maintain my view that SGAs are a second-line intervention when ETI fails. Want to find out why? Join myself and my esteemed colleague Benjamin Dowdy on 21 June 2015 while we debate this issue live. For any further questions or comments, I can be contacted at