The use of laryngeal tube by nurses in out-of-hospital emergencies: Preliminary experience☆
Introduction
In emergency situations, particularly when the level of consciousness is compromised, securing the airway is of paramount importance to ensure adequate ventilation [1], [2]. Hypoxia following an obstructed airway leads to increased morbidity and mortality in both trauma and non traumatic cases [1], [3].
Tracheal intubation is perceived as the overall gold standard for securing the airway because of near complete protection from aspiration [1]. However, this manoeuvre requires skill and continuous training and practice [4], [5], [6]. It is difficult to achieve without sedation and muscle relaxation unless the patient is deeply comatose. As nurses are often not allowed to use drugs, unless under strict medical supervision, tracheal intubation is not a routine intervention [1], [7]. Indeed, the success rate of tracheal intubation in the field may not be higher than 50% when the manoeuvre is performed by inexperienced personnel [8], [9], [10], unless they have specific long term training and experience [1], [11].
Alternative techniques to tracheal intubation have been adopted over the years. Many have been used by inexperienced personnel showing that airway patency can be safely achieved with supraglottic devices [4], [5], [6], [7], [8], [12], [13], [14], [15], [16], [17].
These include devices which are placed without the use of a laryngoscope. The cuffed oro-pharingeal airway (COPA), the esophageal obturator, the laryngeal mask airway (LMA) and its modifications, the intubating laryngeal mask airway (Fast Trach), the ProSeal laryngeal mask, are the most frequently used devices [4], [5], [6], [7], [15], [16], [17], [18], [19], [20]. Their shape and structure allow blind placement into the desired position.
The majority of these devices have been tested previously in the operating room to quantify their effectiveness in terms of ease of insertion, ventilation efficiency, possibility of aspiration and protection from regurgitation [18], [19], [20]. Subsequently, they have been applied in the out-of-hospital practice [5], [11], [12].
The laryngeal tube (LT) is a more recent device designed to be easily placed and to ensure the patency of the airway together with adequate ventilation. Preliminary reports of experience have shown that it is safe and delivers effective ventilation with a good airway seal that prevents aspiration [12], [23], [24], [25], [26], [27], [28], [29], [30].
The device has been used by nurses and inexperienced personnel, but most of the data refer to simulations and manikin tests; limited experience exist on the use of the LT in out-of-hospital emergencies [12], [14], [31], [32], [33]. When compared with the laryngeal mask airway or the ProSeal laryngeal mask, the LT has been demonstrated to be at least as easy to use and as effective as LMA, with a good success rate of insertion and protection from regurgitation [19], [20], [21], [24], [34], [35].
Since in our country out-of-hospital emergency interventions are mostly performed by nurses rather than by physicians, we undertook this study to assess the ease of use and safety of the LT in out-of-hospital emergencies by minimally trained nurses.
Section snippets
Material and methods
Our department covers an area of approximately 2270 km2 and ranges from countryside to mountain areas. The population served by the emergency system is about 90.000 people. The distance from the mountain hospital to the most remote villages may require up to 60 min travel by ambulance. Due to the long distances and the absence of doctors in the ambulances, we decided to attempt to make a step forward in the treatment of out-of-hospital emergencies by training the nurses in the use of a
Results
Between January 2002 and September 2003, 30 adult patients were treated with the LT.
The demographics of the patients were as follows:
There were 18 men and 12 women. The mean age was 75.6 years with a range of 48–98 years. Twenty-nine patients were found in respiratory arrest (96.7%), one was gasping (3.3%); all patients were in cardiac arrest, 7 (23.13%) due to trauma and 23 (76.47%) from a non traumatic cause.
The number of attempts to obtain secure placement is depicted in Fig. 1. In all 21
Discussion
Airway management and respiratory support are required in both basic and advanced life support interventions [1], [2]. Though ALS guidelines indicate tracheal intubation as the preferred procedure for securing the airway to guarantee adequate ventilation, this is more difficult to achieve in the out-of-hospital settings due to the peculiarity of situation (difficulty of the maneuvre, characteristics of the patients, rescuers’ limited experience, etc.) [1], [6].
Tracheal intubation performed by
Conclusions
Although additional training will be certainly required, we support the use of the laryngeal tube as a useful adjunct for paramedic personnel for the management of airway patency and ventilation in out-of-hospital emergencies.
Conflict of interest
The authors state that there are no personal or financial relationship with people or organizations that could have influenced this work.
Acknowledgments
The Authors wish to thank all nurses of the Emergency Department who contributed to the completion of the present work, and particularly: Cristina Bernardon, Alessandra Catto, Luciana Francescani, Silvia Giacomello, Emilia Venier.
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2016, ResuscitationCitation Excerpt :Additionally, several clinical trials suggested, that the I-Gel and the LT would enable adequate ventilation during CPR as well.33–37 In two smaller studies evaluating the LT, the authors also reported that they did not observe any signs of regurgitation in any of their patients.38,39 This seems to be contradictory with the results of our study, and the assumption, that regurgitation can be avoided by using an LT cannot be supported by the findings of our study.
Safety of laryngeal tubes- the authors reply
2016, American Journal of Emergency Medicine
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A Spanish and Portuguese translated version of the Abstract and Keywords of this article appears at 10.1016/j.resuscitation.2004.12.023.