Use of SADs in the prehospital setting – a new review

Ostermayer and Gausche-Hill, in their review paper, ‘Supraglottic airways: The history and current state of prehospital airway adjuncts’, to be published in Prehospital Emergency Care, provide a much welcome overview on the use of supraglottic airways (SADs) in what can often be a difficult and challenging setting.

The paper begins by confirming that the widespread adoption of SADs in prehospital care ‘directly stems from their ease of use, simplicity of training, predictability, and speed of insertion’. It continues with a brief history of the use of SADs, particularly the Laryngeal Mask Airway, in the prehospital setting and includes individual overviews of a number of devices, including the Combitube®, King LT®, LMA Fastrach® and Intersurgical i-gel®.

There is acknowledgement that whilst SADs do not, in the words of the authors, provide ‘definitive airway management’, some of the newer devices do incorporate higher seal pressures than earlier options and the ability for gastric decompression, which ‘may significantly decrease aspiration risk’.

In anaesthesia circles in particular, a new classification of SADs into 1st and 2nd generation devices has gained considerable popularity and helped to highlight important differences between devices. In a review article by White et al, entitled, ‘A critique of elective pediatric supraglottic airway devices’, a 1st generation device was described as a ‘simple airway tube’ and 2nd generation as a device that ‘incorporates specific design features to improve safety by protecting against regurgitation and aspiration.’

Of course, as mentioned in an earlier blog post on the classification of supraglottic airways, designation as a 2nd generation device does not in itself confirm superiority of performance, but the classification does provide useful information about basic product design characteristics, such as whether the device incorporates a mechanism for the management of regurgitant fluid. These are important considerations when deciding the most appropriate SAD to use in the pre-hospital setting.

Discussion on the use of airway devices in the austere environment states that data collection from Combat Support Hospitals in 2008 demonstrated that 86.3% of prehospital managed airways were managed with an Endotracheal tube (ETT), 7.2% with an Esophageal Tracheal Combitube (ETC) and 0.7% with an LMA, and that, ‘although the ETC is the standard rescue airway device for the U.S. Army, poor skill retention has been demonstrated with the device among medics.’

RSA or Rapid Sequence Airway placement, the insertion of an alternative airway, such as a SAD, after pharmacological treatment with a paralytic and sedative is discussed. This is an important subject and Ostermayer and Gausche-Hill confirm that no trials have yet compared the risks and benefits of drug-assisted SAD placement to non-drug-assisted placement.

The final section of the review takes a look at airway management in Out-of-Hospital Cardiac Arrest (OHCA). Of particular interest is a reference to a Japanese study which looked at neurological outcomes in patients where an ETT was used, compared to either a SAD or Bag Valve Mask (BVM). The results are interesting, but it is important when reviewing such studies to consider the SADs that were used. Results are likely to be quite different for 2nd generation SADs such as the i-gel, compared to a 1st generation device such as a standard Laryngeal Mask Airway. In some countries like the UK, devices such as the Combitube® are now rarely, if ever used. This issue is discussed in more depth in my blog post, ‘Pre-hospital airway management for patients with OHCA’.

There are a couple of small errors in the ‘early view’ version of this paper. For example, in Table 1, the i-gel® is designated as reusable, whereas the device is in fact single use. No doubt these errors will be corrected in the final published version.

In summary, this review paper provides an interesting overview of the history and current state of prehospital airway adjuncts. The conclusion will reflect the thoughts of many with regard to this subject:

‘Since prehospital airway management devices largely evolve from the field of anesthesia, much of the medical literature regarding new devices focuses on the operating room. With the many obvious practical and clinical differences between these clinical settings, further studies in the prehospital environment are needed, specifically trials correlating neurologic outcome to supraglottic device’

Equally important will be to ensure that results for one type of SAD are not extrapolated to another with quite different design characteristics. Tempting as it may be to discuss SADs as if they are one homogenous group of devices, the reality, as this paper helps to highlight, is that the performance of each device can and will be quite different. One SAD is most definitely not the same as another. Further data regarding the use of SADs in the prehospital setting is eagerly awaited.