Disposable laryngeal tube suction—A randomized comparison of two insertion techniques performed by novice users in anaesthetised patients

doi:10.1016/j.resuscitation.2007.08.018

Resuscitation

Volume 76, Issue 3, March 2008, Pages 364-368

https://doi.org/10.1016/j.resuscitation.2007.08.018 Get rights and content

Summary

Objective

Laryngeal tubes are supraglottic airway devices that can be used in alternative to a tracheal tube to provide ventilation during cardiopulmonary resuscitation. The product line has recently been expanded by the disposable laryngeal tube suction (LTS-D). We tested the hypothesis that, with a modified insertion technique (MIT), the rate of correct placement attempts within 45 s could be significantly increased compared to the standard insertion technique (SIT) recommended by the manufacturer.

Methods

Fifty-four adult patients undergoing trauma surgery under general anaesthesia had an LTS-D inserted by first-time users, randomly assigned to the SIT or a MIT. A brief manikin-based demonstration of the device and the assigned technique was given before insertion. In the MIT the tip of the LTS-D was rotated by 180° prior to insertion. Forced chin lift to create sufficient retropharyngeal space was performed with the other hand. Introduced to one-third of its length, the LTS-D was again rotated by 180° and pushed down the pharynx. The rate of successful tube placements within 45 s was the main outcome variable.

Results

Insertion took 73 ± 41 s (SIT) and 40 ± 8 s (MIT, P < 0.01). Insertion within 45 s was possible in n = 7/27 patients (26%, SIT) and in n = 20/27 patients (74%, MIT, P < 0.01). In one patient of the MIT group, placement failed. Non-anaesthesia personnel, such as nurses and emergency medical technicians (n = 27), performed comparably to board-certified anaesthesiologists or those in training (n = 27).

Conclusion

Applying a MIT significantly reduced the time for successful insertion of an LTS-D by first-time users. Insertion within 45 s was significantly more frequent with this technique. Further studies need to be conducted to determine if the LTS-D can be recommended as a first-line airway during cardiopulmonary resuscitation.

Introduction

Patients with unexpected difficult airway requiring ventilatory support still remain a challenge for anaesthesiologists, emergency physicians, and emergency medical technicians (EMT). If direct laryngoscopy fails, supraglottic airway devices, i.e. various types of laryngeal tubes, can be used to establish an artificial airway. The disposable laryngeal tube suction (LTS-D) is new, its value is unproven but its design makes it a potentially useful device for emergency use and for cardiopulmonary resuscitation. Other work on similar, but different laryngeal tubes1, 2 led us to consider whether novices might benefit from an alternative insertion techniques.

We tested the hypothesis that, with a modified introduction technique, novice users would be able to successfully place the new LTS-D within 45 s significantly more frequently than using the standard insertion technique recommended by the manufacturer.

Section snippets

Materials and methods

After approval of the study protocol by the institutional review board, 54 adult patients undergoing elective trauma and orthopaedic surgery under general anaesthesia were included in the study. Informed, written consent was obtained on the day before surgery. Sample size estimates suggested that 27 subjects per group would be needed to achieve 80% power to detect an absolute 40% reduction of LTS-D placement attempts lasting longer than 45 s (α = 5%) between standard and modified insertion

Results

No patient had predictors for a difficult airway, nor a history of difficult intubation. Also, no insertion attempt had to be aborted because of oxygen desaturation or exceeding the time limit of 180 s, and all 54 patients completed the study.

There were no clinically important differences between groups in terms of age, height, weight, and body mass index (Table 2).

All users were novices regarding clinical use of any type of laryngeal tubes regardless of the technique applied. LTS-D placement

Discussion

With a modified insertion technique using a reverse, “Guedel tube-like” approach and forced chin lift, inexperienced personnel was able to sufficiently place a LTS-D in anaesthetized patients significantly more frequently within a 45 s time frame than with the classic technique recommended by the manufacturer of the device. We could also find that non-anaesthesia personnel, such as EMT's, nurses, or medical students, performed comparably to board-approved anaesthesiologists or those in training.

Conflict of interest statement

The laryngeal tubes were provided free of charge by VBM Medizintechnik, Sulz, Germany. There were no other sources of funding. None of the authors has any conflict of interest with products and/or companies mentioned in the manuscript that could potentially bias their work.

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The SIT/JT technique required more time than the FIT/JT technique, however, LTS-D placement within the 180 s time frame was successful in 91% of patients and thus almost comparable to the FIT/JT technique. This study confirms the results of a previous investigation, during which entire novices also performed significantly more successful to insert the LTS-D with another modified technique in anaesthetised patients with normal airways.9 The modified technique also consisted of a jaw thrust manoeuvre.
The disposable laryngeal tube suction (LTS-D) is a supraglottic airway device that can be used as an alternative to tracheal tube to provide ventilation. We tested the hypothesis that, with a frontal jaw thrust insertion technique (FIT/JT), the rate of correct placement attempts in patients with a simulated difficult airway by means of a rigid cervical immobilization collar could be significantly increased compared to the standard insertion technique (SIT) recommended by the manufacturer.
70 adult patients undergoing trauma surgery under general anaesthesia had an LTS-D inserted, randomly assigned to the SIT or FIT/JT. In the FIT/JT, the operator was standing in front of the patient's head, and forced chin lift to create sufficient retropharyngeal space was performed. The rate of successful tube placements within 180 s and with a maximum of two attempts was the main outcome variable. To distinguish between the effects of the frontal approach and the jaw thrust manoeuvre, a third group was studied after completion of the SIT and FIT/JT groups. The standard insertion technique, but with a jaw thrust manoeuvre (SIT/JT), was employed in another 35 consecutive patients.
Overall placement success was 49% (SIT, 17/35 patients, P < 0.001), 91% (SIT/JT, 32/35 patients) and 100% (FIT/JT). The time required for successful insertion was shortest in the FIT/JT group (23 ± 6 s), and significantly longer in the SIT/JT (42 ± 29 s, P < 0.001) and SIT groups (51 ± 29 s, P < 0.0001).
In anaesthetised patients with a simulated difficult airway created with a rigid cervical collar, the overall LTS-D placement success was significantly higher when a jaw thrust manoeuvre was performed, regardless of the particular technique used to introduce the LTS-D. Therefore, an intense jaw thrust manoeuvre should be performed whenever an LTS-D is being inserted.
Out-of-hospital airway management by paramedics and emergency physicians using laryngeal tubes
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The outstanding importance of continuous chest compressions and short no-flow intervals during cardiopulmonary resuscitation was emphasised in the 2005 ERC guidelines.2 Several manikin studies demonstrated that the use of a laryngeal tube significantly reduces such no-flow intervals.18,20–23 We could demonstrate that establishing an airway with the laryngeal tube required less than 45 s in most of the cases.
Endotracheal intubation (ETI) is considered to be the gold standard of prehospital airway management. However, ETI requires substantial technical skills and ongoing experience. Because failed prehospital ETI is common and associated with a higher mortality, reliable airway devices are needed to be used by rescuers less experienced in ETI. We prospectively evaluated the feasibility of laryngeal tubes used by paramedics and emergency physicians for out-of-hospital airway management.
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Of 157 prehospital intubation attempts with the LT-D/LTS-D, 152 (96.8%) were successfully performed by paramedics (n = 70) or emergency physicians (n = 87). The device was used as initial airway (n = 87) or rescue device after failed ETI (n = 70). The placement time was ≤45 s (n = 120), 46–90 s (n = 20) and >90 s (n = 7). In five cases the time needed was not specified. The number of placement attempts was one (n = 123), two (n = 25), three (n = 2) and more than three (n = 2). The majority of users (61.1%) were relative novices with no more than five previous laryngeal tube placements.
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Difficult paediatric airways, both expected and unexpected, present major challenges to every anaesthesiologist, paediatrician and emergency physician. However, the integration of supraglottic airway devices, such as the laryngeal mask (LM), into the algorithm of difficult airways has improved the handling of difficult airway situations in patients. A recent device for establishing a supraglottic airway is the laryngeal tube, introduced in 1999. We report on the successful use of the laryngeal tube suction II (LTS II) in securing the airway when endotracheal intubation or alternative mask ventilation has failed.
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Use of the LTS II was associated with a high level of success (100%), often rescuing the airway when other techniques had failed. All insertions were successful on first attempt using a modified insertion technique. Placement was classified as “easy” by all users.
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^☆: A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2007.08.018.

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Clinical paperDisposable laryngeal tube suction—A randomized comparison of two insertion techniques performed by novice users in anaesthetised patients☆

Summary

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Conflict of interest statement

Ann Emerg Med

Ann Emerg Med

Ann Fr Anesth Reanim

Comparison of airway management with the intubating laryngeal mask, laryngeal tube and CobraPLA® by paramedical students in anaesthetized patients

Acta Anaesthesiol Scand

Clinical paper
Disposable laryngeal tube suction—A randomized comparison of two insertion techniques performed by novice users in anaesthetised patients☆

Comparison of airway management with the intubating laryngeal mask, laryngeal tube and CobraPLA^® by paramedical students in anaesthetized patients