You are here: Home » The Playbook » Supraglottic Airways

Supraglottic Airways

When you give only after you’re asked, you’ve waited too long.

– John Mason

First, learn to bag

Place a towel roll under the scapulae to align oral, pharyngeal, and tracheal axes:

Karsli C. Can J Anesth. 2015.

Use airway adjuncts such as the oropharyngeal airway or a nasal trumpet.

Use the two-hand ventilation technique whenever possible:

 

(See Adventures in RSI for more)

 

Supraglottic Airways:

for difficult bag-valve-mask ventilation or a difficult airway

(details in audio)

LMA Classic

Pros: Best studied; sizes for all ages

Cons: Cannot intubate through aperture

 

LMA Supreme

Pros: Better ergonomics with updated design; bite bloc; port for decompression

Cons: Cannot pass appropriate-sized ETT through tube

 

King Laryngeal Tube

Pros: Little training needed; high success rate; single inflation port

Cons: Flexion of tube can impede ventilation or cause leaks; Update: King now makes a size 0 for infants < 5 kg (March, 2017)

 

Air-Q

Pros: Easy to place; can intubate through aperture

Cons: Not for neonates less than 4 kg

 

iGel

Pros: Molds more accurately to supraglottis; no need to inflate; good seal pressures

Cons: Cannot intubate through (without fiberoscopy)

 

Summary

• If you can bag the patient, you’re winning.

• If you have difficulty bagging, or anticipate or encounter a difficult airway, then don’t forget your friend the supraglottic airway (SGA).

• Ego is the enemy of safety: SGAs are simple, fast, and reliable.

• Just do it.

 

References

Ahn EJ et al. Comparative Efficacy of the Air-Q Intubating Laryngeal Airway during General Anesthesia in Pediatric Patients: A Systematic Review and Meta-Analysis. Biomed Res Int. 2016;2016:6406391.

Black AE, Flynn PE, Smith HL, Thomas ML, Wilkinson KA; Association of Pediatric Anaesthetists of Great Britain and Ireland. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth. 2015 Apr;25(4):346-62.

Byars DV et al. Comparison of direct laryngoscopy to Pediatric King LT-D in simulated airways. Pediatr Emerg Care. 2012 Aug;28(8):750-2. 

Carlson JN, Mayrose J, Wang HE. How much force is required to dislodge an alternate airway? Prehosp Emerg Care. 2010 Jan-Mar;14(1):31-5.

Diggs LA, Yusuf JE, De Leo G. An update on out-of-hospital airway management practices in the United States. Resuscitation. 2014 Jul;85(7):885-92.

Ehrlich PF et al. Endotracheal intubations in rural pediatric trauma patients. J Pediatr Surg. 2004 Sep;39(9):1376-80.

Hernandez MR, Klock PA Jr, Ovassapian A. Evolution of the extraglottic airway: a review of its history, applications, and practical tips for success. Anesth Analg. 2012 Feb;114(2):349-68. 

Huang AS, Hajduk J, Jagannathan N. Advances in supraglottic airway devices for the management of difficult airways in children. Expert Rev Med Devices. 2016;13(2):157-69.

Jagannathan N, Wong DT. Successful tracheal intubation through an intubating laryngeal airway in pediatric patients with airway hemorrhage. J Emerg Med. 2011 Oct;41(4):369-73. 

Jagannathan N et al. Elective use of supraglottic airway devices for primary airway management in children with difficult airways. Br J Anaesth. 2014 Apr;112(4):742-8.

Jagannathan N, Ramsey MA, White MC, Sohn L. An update on newer pediatric supraglottic airways with recommendations for clinical use. Paediatr Anaesth. 2015 Apr;25(4):334-45.

Karsli C. Managing the challenging pediatric airway: Continuing Professional Development. Can J Anaesth. 2015 Sep;62(9):1000-16.

Luce V et al. Supraglottic Airway Devices vs Tracheal Intubation in Children: A Quantitative Meta-Analysis of Respiratory Complications. Paediatr Anaesth 24 (10), 1088-1098.

Nicholson A et al. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. Cochrane Database Syst Rev. 2013 Sep 9;(9):CD010105.

Ostermayer DG, Gausche-Hill M. Supraglottic airways: the history and current state of prehospital airway adjuncts. Prehosp Emerg Care. 2014 Jan-Mar;18(1):106-15. 

Rosenberg MB, Phero JC, Becker DE. Essentials of airway management, oxygenation, and ventilation: part 2: advanced airway devices: supraglottic airways. Anesth Prog. 2014 Fall;61(3):113-8. 

Schmölzer GM, Agarwal M, Kamlin CO, Davis PG. Supraglottic airway devices during neonatal resuscitation: an historical perspective, systematic review and meta-analysis of available clinical trials. Resuscitation. 2013 Jun;84(6):722-30.

Sinha R, Chandralekha, Ray BR. Evaluation of air-Q™ intubating laryngeal airway as a conduit for tracheal intubation in infants–a pilot study. Paediatr Anaesth. 2012 Feb;22(2):156-60.

Timmermann A. Supraglottic airways in difficult airway management: successes, failures, use and misuse. Anaesthesia. 2011 Dec;66 Suppl 2:45-56.

Timmermann A, Bergner UA, Russo SG. Laryngeal mask airway indications: new frontiers for second-generation supraglottic airways. Curr Opin Anaesthesiol. 2015 Dec;28(6):717-26.

 

150px-WikEM_app_Logo

Supraglottic Airway on WikEM

 

This post and podcast are dedicated to Tim Leeuwenburg, MBBS FRACGP FACRRM DRANZCOG DipANAES and Rich Levitan, MD, FACEP for helping to keep our minds — and our patients’ airways — open.  You make us better doctors.  Thank you.

Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP

Special thanks to Doug McDaniel, FP-C, for an update on King airways.  Thanks, Doug!

Pediatric; Emergency Medicine; Pediatric Emergency Medicine; Podcast; Pediatric Podcast; Emergency Medicine Podcast; Horeczko; Harbor-UCLA; Presentation Skills; #FOAMed #FOAMped #MedEd

  • Andrew Tagg

    Another great podcast with the perfect visual accompaniment.

    As I walked to work this morning, listening at normal speed, I was interested in your discussion regarding the amount of force required to dislodge an ETT. I would suggest that we can’t really extrapolate the data from 5 adult cadavers to a paediatric population.

    Rather than force required to dislodge the ETT I find a bigger issue is movement. One a neonate has been intubated very little neck extension is required to move the tube a centimetre or two. Do you have a good resource on how you secure either the LMA’s or ETT’s that you can share?

    Andy

    • Tim Horeczko

      Thank you, Andy, for your support, and for listening at the speed Nature intended (1x!).

      You are absolutely correct; this was not a comparison study, but a descriptive analysis. Kudos to Carlson et al. for the study — I think it offers some context vis-a-vis force to dislodge ETT and various supraglottic airways. Extrapolation here is the standard — use adult data if pediatric data are not available and they makes physiologic sense. In this case, the a priori argument may be that the poorly supported soft tissues and relatively large tongue in children would actually favor a better seal and more difficult dislodgement than in adults. The take-home for me is that, if placed and secured properly, don’t fear the SGA.

      I’ll need to do another episode on pitfalls post-intubation — the neonate (or any age patient, really) in your scenario will be very sensitive to changes in neck flexion/extension. Small changes in either will pull the tube up or down — the tip follows the nose! Keep the child midline and neutral after intubation.

      As far as securing method, I prefer the Lillehei taping method, shown to be the least likely to allow for dislodgement by a study by Owen et al.: https://www.ncbi.nlm.nih.gov/pubmed/19726121 and another by Carlson et al.:https://www.ncbi.nlm.nih.gov/pubmed/17599694

      Here is a general video on taping:

      Here is one specifically on neonates:

      A slightly livelier version, but well done:
      https://www.youtube.com/watch?v=sopfI9yFRg8

      Secure SGAs just as you would ETTs.

      Thanks, Andy, for your ever great comments, questions, ponderings, and supplementation.

  • Hosam

    very informative. thank you