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.

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