310 Correspondence/ American Journal of Emergency Medicine 34 (2016) 307-337

Andrzej Kurowski, PhD, MD

Department of Anesthesiology Cardinal Wyszynski National Institute of Cardiology, Warsaw, Poland

Lukasz Czyzewski, PhD, RN

Department of Nephrologic Nursing Medical University of Warsaw, Warsaw, Poland

Togay Evrin, PhD, MD Department of Emergency Medicine, UFuK University Medical Faculty Dr Ridvan Ege Education and Research Hospital, Ankara, Turkey

Lukasz Bogdanski, MD

Department of Anesthesiology Cardinal Wyszynski National Institute of Cardiology, Warsaw, Poland

Figure. VivaSight-SL endotracheal tube used in study.

Prior the study, all participants were given a 30-minute standard training session. The equipment was demonstrated in detail by ex- perienced anesthesiologist. After theoretical section participants were given ten minutes to practice intubation, with the instructor available to give advice. After the practice session, the participants were divided into four groups. The study was designed as a randomized crossover trial to minimize learning effects. Research Randomizer program was used [www.randomizer.com]. Participants were not allowed to watch each other during any of the intubation attempts to avoid any learning effects throughout the procedure. Each par- ticipant was instructed to insert the ET tube, attach a bag valve mas, and attempt to ventilate lungs of the manikin. Participants were reminded that the patient needs emergency endotracheal in- laryngeal tubes?”>tubation as fast as possible before each attempt to give them a cer- tain feeling of time pressure that would have been presented in real emergency situations.

The primary outcome was the time to intubation. Time was started when the participant picked up the ETView or MAC and ended at the point of manual ventilation after ET insertion. Secondary outcome was success of the first intubation attempt. Success of the intubation attempt was recorded when the success of the ventilation attempt was seen by the manikins ventilation indicators. The Statistica statistical package (ver.12.0 for Windows, StatSoft, Tulusa, OK) was used for statistical analysis. P b .05 was considered statistically significant.

The analysis showed that the shortest median intubation time

during scenario A was achieved with ETView (19 [IQR, 17-22.5] s) and the longest when using MAC (25 [IQR, 23.5-29] s). Those difference was statistically significant (P b .001). Similar dependence was ob- served in scenario B, where time to intubation using ETView was 22.5 [IQR, 20-26] s, and using MAC was 39 [IQR, 31-47.5] s (P b .001). The

success rate after the first attempt using the distinct intubation methods varied and amounted to 100% vs 72.3% (ETView, MAC, respectively) for scenario A and 96.4% vs 46.4%, respectively for scenario B.

In conclusion, this study indicates that the ETView may be a good first choice in tracheal intubation by a paramedic in a cervical immobilized condition and CIC with tongue swelling, due to the improved first- attempt success rate and shorter intubation time.

Lukasz Szarpak, PhD, MPH, EMT-P* Zenon Truszewski, PhD, MD Department of Emergency Medicine

Medical University of Warsaw, Warsaw, Poland

?Corresponding author. Department of Emergency Medicine Medical University of Warsaw, Lindleya 4 Str., 02-005, Warsaw, Poland

http://dx.doi.org/10.1016/j.ajem.2015.10.013

References

1. Prasad VS, Schwartz A, Bhutani R, Sharkey PW, Schwartz ML. Characteristics of injuries to the cervical spine and spinal cord in polytrauma patient population: experience from a regional trauma unit. Spinal Cord 1999;37(8):560-8.
2. Kurowski A, Szarpak L, Truszewski Z, Czyzewski L. Can the ETView VivaSight SL Rival Conventional Intubation Using the Macintosh Laryngoscope During Adult Resuscitation by novice physicians?: A Randomized Crossover Manikin Study. Medicine (Baltimore) 2015;94(21). http://dx.doi.org/10.1097/MD.0000000000000850.
3. Rodriguez-Nunez A, Moure-Gonzalez J, Rodriguez-Blanco S, Oulego-Erroz I, Rodriguez-Rivas P, Cortinas-Diaz J. Tracheal intubation of Pediatric manikins during ongoing chest compressions. Does Glidescope(R) videolaryngoscope improve pediatric residents’ performance? Eur J Pediatr 2014;173(10):1387-90. http://dx.doi.org/10. 1007/s00431-014-2329-z.
4. Szarpak L, Czyzewski L, Kurowski A. Can GlideScope(R) videolaryngoscope be an alterna- tive to direct laryngoscopy for child and infant tracheal intubation during chest compres- sion? Eur J Pediatr 2015;174(7):981-2. http://dx.doi.org/10.1007/s00431-015-2495-7.
5. Cobas MA, De la Pena MA, Manning R, Candiotti K, Varon AJ. prehospital intubations and mortality: a level 1 trauma center perspective. Anesth Analg 2009;109(2): 489-93. http://dx.doi.org/10.1213/ane.0b013e3181aa3063.

   Safety of Laryngeal tubes?

   

   To the Editor,

   We read with interest the study by Roth et al [1]. The authors concluded that Prehospital use of the Laryngeal tube during out-of-hospital cardiac arrest (OHCA) by basically trained emergency medical technicians seems to be safe and feasible and that “injuries were relatively rare.” It should be emphasized that the LT is by no means an airway device without complications [1] given the high incidence of severe and Life-threatening complications with prehospital LT use (98/189 patients; 52%) [2], which is preventable in some cases using a device with gastric drainage [3]. Roth et al [1] reported cases of regurgitation in both the bag mask ventilation (BVM) (8/74; 11%) and LT group (22/395; 6%); this is comparable to data from another prehospital study [6]. They also found a high number of cuff ruptures in the LT group (16/395; 4%) [1]. The complication rate increased when ventilation with the LT could not be achieved and the user resorted to BVM (regurgitation 8/48 [17%], injury 1/48 [2%], and cuff rupture 3/48 [6%]). In our study [4], we compared BVM with 2 supraglottic devices with gastric access, as recommended [2,3]. Stomach insufflation (confirmed by epigastric auscultation) was common and not statistically different between groups (BVM 11/33 [33%], laryngeal mask 20/47 [41%], and LT 15/39 [39%]; P = .789), which seems to underline this recommendation

   Tel.: +48 500186225 (Mobile)

   E-mail address: [email protected]

   ? The authors declare no conflict of interest.

   Correspondence/ American Journal of Emergency Medicine 34 (2016) 307-337 311

   [4]. The nurses involved in our study [4] had no advanced training, as mentioned by the authors [1], but received only a 1-hour theoretical and hands-on training with all 3 devices. To avoid a learning effect during the study period, the nurses were randomly assigned to use the same device a maximum of 3 times. The insertion success of LTs (first attempt 300/395 [70%] and second attempt 91/395 [23%]) [1] is comparable to other clinical and prehospital studies [4-6], independent of the user’s experience of air- way management. In a study by Russo et al [5], for example, 2 senior anes- thesiologists had an insertion success of 70% using the laryngeal tube suction disposable in anesthetized patients [5]; in a study by Lankimaki et al [6], paramedics had a first attempt success in an OHCA situation in 46 (72%) of 64 and second attempt success in 13 (20%) of 64 cases [6]. There are several reasons why training with LTs on anesthetized patients-though recommended [7]-is still not common, for example,

   (i) the insertion success rate on the first attempt is much higher using la- ryngeal masks compared with LTs in different clinical studies [4,5], (ii) LMs are simply used more frequently in clinical settings [3], and (iii) air- way morbidity is higher with LT including dysphagia, soft tissue injuries, and tongue swelling [2,4,5]. Because advanced airway management plays such a central role in OHCA scenarios, there should be continued focus on well-designed, randomized Prospective trials with supraglottic airway devices for basically trained personnel, evaluating not only inser- tion success but also the effects of Ventilation parameters on patient outcome.

   Rosmarie Oberhammer, MD* Elisabeth Gruber, MD¹

   General Hospital Bruneck, Spitalstrasse 11, 39031 Bruneck, Italy

   ?Corresponding author. Tel.: +39 0474581660

   E-mail addresses: [email protected],

   [email protected]

   ¹ Tel.: +39 0474581660

   Hermann Brugger, MD Giacomo Strapazzon, MD, PhD

   International Commission for Mountain Emergency Medicine, ICAR MEDCOM, EURAC Institute of Mountain Emergency Medicine, Bozen, Italy

   E-mail addresses: [email protected],

   [email protected]

   Emily Procter, MSc EURAC Institute of Mountain Emergency Medicine, Bozen, Italy

   E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.10.048

   References

   Roth D, Hafner C, Aufmesser W, Hudabiunigg K, Wutti Ch, Herkner H, et al. Safety and feasibility of the laryngeal tube when used by EMTs during out-of-hospital cardi- ac arrest. Am J Emerg Med 2015;33:1050-5. http://dx.doi.org/10.1016/j.ajem.2015. 04.048.

6. Schalk R, Seeger FH, Mutlak H, Schweigkofler U, Zacharowski K, Peter N, et al. Complications associated with the prehospital use of laryngeal tubes-a systematic analysis of risk factors and strategies for prevention. Resuscitation 2014;85: 1629-32. http://dx.doi.org/10.1016/j.resuscitation.2014.07.014.
7. Paal P, Timmermann A. The beauty and the beast-a tale of the laryngeal tube and related potentially life threatening operational faults. Resuscitation 2014;85:A1-2. http://dx.doi.org/10.1016/j.resuscitation.2014.09.006.
8. Gruber E, Oberhammer R, Balkenhol K, Strapazzon G, Procter E, Brugger H, et al. Basic life support Trained nurses ventilate more efficiently with laryngeal mask supreme than with facemask or laryngeal tube suction-disposable-a prospective, randomized clinical trial. Resuscitation 2014;85:499-502. http://dx.doi.org/10.1016/j.resuscita- tion.2014.01.004.
9. Russo SG, Cremer S, Galli T, Eich Ch, Brauer A, Crozier TH, et al. Randomized comparison of the i-gel, the LMA Supreme, and the Laryngeal Tube Suction-D using clinical and fiberoptic assessments in elective patients. BMC Anesthesiol 2012;12:18. http://dx.doi.org/10.1186/1471-2253-12-18.
10. Lankimaki S, Alahuhta S, Kurola J. Feasibility of laryngeal tube for airway management during cardiac arrest by First responders. Resuscitation 2013;84:446-9. http://dx.doi. org/10.1016/j.resuscitation.2012.08.326.
11. Deakin CD, Murphy D, Couzins M, Mason S. Does an advanced life support course give non-anaesthetists adequate skills to manage an airway? Resuscitation 2010;81(5): 539-43. http://dx.doi.org/10.1016/j.resuscitation.2010.02.001.

    Safety of laryngeal tubes-the authors reply

    

    To the Editor,

    We thank Oberhammer and colleagues for their interest in our article on safety and feasibility of the laryngeal tube (LT) in out-of-hospital car- diac arrest (OHCA) [1]. In this study on airway management by emergen- cy medical technicians in 517 cases of OHCA, we showed a success rate of 93% using the LT as compared with 30% using Bag valve mask ventilation (P = .01), as well as a regurgitation rate of 6% vs 11% (P = .01).

    They reference a study they performed in which basically trained nurses performed ventilation using bag valve mask, LT with suction lumen, and the laryngeal mask [2]. In 150 patients, they observed a fail- ure rate of 34%, 22%, and 2%, respectively [3]. Whereas this work is clear- ly of interest, it is hardly comparable with our study, as it was performed in the operating theater on American Society of Anesthesiologists 1-2 patients scheduled for elected surgery as compared with patients suf- fering OHCA in our study.

    They also stress that “the laryngeal tube is by no means an airway device without complications” [3]. We could not agree more with this appraisal. However, our study [1], together with numerous other ones [4-8], suggests that, just like many other tools in emergency medicine, the LT can be the right device when used in the right hands and at the right situation.

    Dominik Roth, MD Wolfgang Schreiber, MD Harald Herkner, MD^?

    Department of Emergency Medicine, Medical University of Vienna, Austria

    ^?Corresponding author. Department of Emergency Medicine Medical University Vienna, General Hospital Wahringer Gurtel 18-20, 1090, Vienna, Austria

    Tel.: +43 1 40400 39640; fax: +43 1 40400 19650

    E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.11.005

    References

    Roth D, Hafner C, Aufmesser W, Hudabiunigg K, Wutti Ch, Herkner H, et al. Safety and feasibility of the laryngeal tube when used by EMTs during out-of-hospital cardiac ar- rest. Am J Emerg Med 2015;33:1050-5. http://dx.doi.org/10.1016/j.ajem.2015.04.048.

12. Gruber E, Oberhammer R, Balkenhol K, Strapazzon G, Procter E, Brugger H, et al. Basic life support trained nurses ventilate more efficiently with laryngeal mask supreme than with facemask or laryngeal tube suction-disposable-a prospective, randomized clinical trial. Resuscitation 2014;85:499-502. http://dx.doi.org/10.1016/j.resuscita- tion.2014.01.004.
13. Oberhammer R, Gruber E, Brugger H, Strapazzon G, Procter E. Safety of laryngeal tubes. Am J Emerg Med 2016;34:310-1.
14. Kette F, Reffo I, Giordani G, Buzzi F, Borean V, Cimarosti R, et al. The use of laryngeal tube by nurses in out-of-hospital emergencies: preliminary experience. Resuscitation 2005;66:21-5.
15. Heuer JF, Barwing J, Eich C, Quintel M, Crozier TA, Roessler M. Initial ventilation through laryngeal tube instead of face mask in out-of-hospital cardiopulmonary ar- rest is effective and safe. Eur J Emerg Med 2010;17:10-5.
16. Gahan K, Studnek J, Vandeventer S. King LT-D use by urban basic life support first re- sponders as the primary airway device for out-of-hospital cardiac arrest. Resuscita- tion 2011;82:1525-8.
17. Lankimaki S, Alahuhta S, Kurola J. Feasibility of a laryngeal tube for airway management during cardiac arrest by first responders. Resuscitation 2013 Apr;84(4):446-9.
18. Tritsch L, Boet S, Pottecher J, Joshi GP, Diemunsch P. Intubating laryngeal mask airway placement by non-physician healthcare providers in management out-of-hospital cardiac arrests: a case series. Resuscitation 2014;85:320-5.