European Resuscitation Council Guidelines for Resuscitation.

Although there are numerous supraglottic airway alternatives to endotracheal intubation, it remains unclear which airway technique is optimal for use in prehospital cardiac arrests. We evaluated the use of the laryngeal tube (LT) as an airway management tool among adult out-of-hospital cardiac arrest (OHCA) patients treated by our ambulance services in the Haukeland and Innlandet hospital districts. Post-resuscitation forms and data concerning airway management in 347 adult OHCA victims were retrospectively assessed with regard to LT insertion success rates, ease and speed of insertion and insertion-related problems. A total of 402 insertions were performed on 347 OHCA patients. Overall, LT insertion was successful in 85.3% of the patients, with a 74.4% first-attempt success rate. In the minority of patients (n = 46, 13.3%), the LT insertion time exceeded 30 seconds. Insertion-related problems were recorded in 52.7% of the patients. Lack of respiratory sounds on auscultation (n = 100, 28.8%), problematic initial tube positioning (n = 85, 24.5%), air leakage (n = 61, 17.6%), vomitus/aspiration (n = 44, 12.7%), and tube dislocation (n = 17, 4.9%) were the most common problems reported. Insertion difficulty was graded and documented for 95.4% of the patients, with the majority of insertions assessed as being “Easy” (62.5%) or “Intermediate” (24.8%). Only 8.1% of the insertions were considered to be “Difficult”. We found a high number of insertion related problems, indicating that supraglottic airway devices offering promising results in manikin studies may be less reliable in real-life resuscitations. Still, we consider the laryngeal tube to be an important alternative for airway management in prehospital cardiac arrest victims.

/pdf/laryngeal-tube-use-in-out-of-hospital-cardiac-arrest-by-27blwtzbov.pdf

Laryngeal tube use in out-of-hospital cardiac arrest by paramedics in Norway

Summary


During emergency care, the ability to ventilate the patient's lungs is a crucial skill. Supraglottic airway devices have an established role in emergency care, and manikin trials have shown that placement is easy even for inexperienced users. However, there is current discussion as to what extent these results can be transferred to patients. We studied the transfer of skills learnt on a manikin to the clinical situation in novice medical students during their anaesthesia rotation. They were required to ventilate the lungs of a manikin using a facemask and then position a supraglottic airway device (LMA-Supreme™) and ventilate the lungs. This process was then repeated on anaesthetised patients, with standard ventilator settings to assess adequacy of ventilation. Sixty-three students participated in the manikin study. The success rate for ventilating the lungs was 100% for both devices, but the mean (SD) time to achieve successful ventilation was 27.8 (24.4) s with the facemask compared with 38.6 (22.0) s with the LMA-Supreme (p = 0.008). Fifty-one of the students progressed to the second part of the study. In anaesthetised patients, the success rate for ventilating the lungs was lower for the facemask, 27/41 (66%) compared with the LMA-Supreme 37/41 (90%, p = 0.006). For 26 students who succeeded with both devices, the tidal volume was lower using the facemask, 431 (192) ml compared with the LMA-Supreme 751 (221) ml (p = 0.001), but the time to successful ventilation did not differ, 60.0 (26.2) s vs 57.3 (26.6) s (p = 0.71). We conclude that the results obtained in manikin studies cannot be transferred directly to the clinical situation and that guidelines should take this into account. Based on our findings, a supraglottic airway device may be preferable to a facemask as the first choice for inexperienced emergency caregivers.

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/pdf/10.1111/anae.12367

Transfer of airway skills from manikin training to patient: success of ventilation with facemask or LMA-SupremeTM by medical students

Supraglottic devices are helpful for inexperienced providers who perform ventilation in emergency situations Most supraglottic devices do not allow secondary tracheal intubation through the device The novel intubating laryngeal tube (iLTS-D®) and the intubating laryngeal mask (Fastrach™) are devices that offer supraglottic ventilation and secondary tracheal intubation We evaluated the novel iLTS-D and compared it to the established Fastrach using a manikin-based study Participants used both devices in a randomised order The participants conducted four consecutive trials on a manikin One trial was composed of the following procedures First, participants ventilated the manikin using either iLTS-D or Fastrach ‘Time to ventilation’, success rates and number of attempts were recorded for the supraglottic device Second, participants intubated the manikin through the previously inserted supraglottic device ‘Time to tracheal ventilation’, success rate and tube localisation were recorded The primary endpoint was the results of the final fourth trial, which mirrored the standardised training of trials 1, 2 and 3 A total of 64 participants were enrolled All of the participants successfully inserted both devices on their first attempt in trial 4 Fastrach was applied 1 s faster in trial 4 than the iLTS-D (median ‘time to ventilation’ Fastrach: 135 s, iLTS-D: 145 s, p = 004) All participants successfully intubated through both devices in trial 4 There was no difference in ‘time to tracheal ventilation’ by tracheal intubation between either device (median ‘time to tracheal ventilation’: Fastrach: 140 s, iLTS-D: 140 s, p = 016) The iLTS-D performed similarly to the ILMA in insertion and intubation times in a manikin setting

/pdf/the-novel-intubating-laryngeal-tube-ilts-d-is-comparable-to-lj4jugb1sw.pdf

The novel intubating laryngeal tube (iLTS-D) is comparable to the intubating laryngeal mask (Fastrach) – a prospective randomised manikin study

: A comprehensive literature review on the topics yielded numerous publications for cholinergic crisis (1,032) and pediatric/neonatal intubation (475). These results provided a foundation for the following in both clinical domains: creation of comprehensive task analyses, identification of critical tasks and standards of performance, curriculum deficits, strengths and weaknesses of various training platforms (simulation, animal, multimedia), and development of assessment instruments (cognitive, psychomotor, affective). Validation data were collected for pediatric/neonatal intubation instruments. All assessment instruments were reviewed by experts and statistical calculations (ANOVA) to evaluate the construct validity for each of the five assessment instruments indicated that each were able to differentiate between all provider experience levels at p=.000 significance. Reliability calculations (Cronbach s alpha) demonstrated excellent reliability ranging between .82 and .95. Subject distribution at this reporting time is Animal (N=127) and Simulator (N=167). Preliminary results show all subjects significantly improved with both interventions (p=.000). Retention assessment will continue through 2014. Instructional components and collection of sufficient data for assessment instrument validation for the cholinergic crisis arm were completed in Q3-2013 and Q4-2013, respectively.

Critical Analyses and Development of Training Mechanisms: Cholinergic Crisis and Pediatric/Neonatal Intubation

Supraglottic airway devices have frequently been shown to facilitate airway management and are implemented in the ILCOR resuscitation algorithm. Limited data exists concerning laypersons without any medical or paramedical background. We hypothesized that even laymen would be able to operate supraglottic airway devices after a brief training session. Four different supraglottic airway devices: Laryngeal Mask Classic (LMA), Laryngeal Tube (LT), Intubating Laryngeal Mask (FT) and CobraPLA (Cobra) were tested in 141 volunteers recruited in a technical university cafeteria and in a shopping mall. All volunteers received a brief standardized training session. Primary endpoint was the time required to definitive insertion. In a short questionnaire applicants were asked to assess the devices and to answer some general questions about BLS. The longest time to insertion was observed for Cobra (31.9 ± 27.9 s, range: 9-120, p 0.05), the LT (1.36 ± 0.61, p 95%. The use of supraglottic airway devices in first aid and BLS algorithms should be considered.

/pdf/laypersons-can-successfully-place-supraglottic-airways-with-2yvivghng1.pdf

Laypersons can successfully place supraglottic airways with 3 minutes of training. A comparison of four different devices in the manikin

The posterior dominant rhythm (PDR) was the first oscillatory pattern noted in the EEG. Evoked by wakeful eyelid closure, these oscillations dissipate over seconds during loss of arousal. The peak frequency of the PDR maintains stability over years, suggesting utility as a state biomarker in the surveillance of acute cognitive impairments. This EEG signature has not been systematically investigated for tracking cognitive dysfunction after anaesthetic-induced loss of consciousness.This substudy of Reconstructing Consciousness and Cognition (NCT01911195) investigated the PDR and cognitive function in 60 adult volunteers randomised to either 3 h of isoflurane general anaesthesia or resting wakefulness. Serial measurements of EEG power and cognitive task performance were assessed relative to pre-intervention baseline. Mixed-effects models allowed quantification of PDR and neurocognitive trajectories after return of responsiveness (ROR).Individuals in the control group showed stability in the PDR peak frequency over several hours (median difference/inter-quartile range [IQR] of 0.02/0.20 Hz, P=0.39). After isoflurane general anaesthesia, the PDR peak frequency was initially reduced at ROR (median difference/IQR of 0.88/0.65 Hz, P<0.001). PDR peak frequency recovered at a rate of 0.20 Hz h-1. After ROR, the PDR peak frequency correlated with reaction time and accuracy on multiple cognitive tasks (P<0.001).The temporal trajectory of the PDR peak frequency could be a useful perioperative marker for tracking cognitive dysfunction on the order of hours after surgery, particularly for cognitive domains of working memory, visuomotor speed, and executive function.NCT01911195. 

The posterior dominant rhythm: an electroencephalographic biomarker for cognitive recovery after general anaesthesia.

Background: “Chest compressions only” resuscitation (CCOR) has been suggested one method of increasing laypersons attendance providing bystander resuscitation, avoiding mouth-to-mouth (MTM) ventilation and improving patients’ outcome. In prolonged CCOR without rescue breaths and a non-cardiac origin, neurological outcome is very much dependent on oxygenation. As an alternative to MTM we investigated laypersons ability to operate supraglottic airway devices (SAD) in the manikin, following illustrated on-site instruction. Methods: Laypersons were handed a bag containing either an LMAS or an LT, a bag-mask-valve device (BMV), a syringe prefilled with air, and an instruction manual consisting of four annotated diagrams displaying the correct use of either the Laryngeal Mask Supreme™ (LMAS) or the Laryngeal Tube™ (LT). They were then asked to perform and ventilate a manikin as displayed. The process was evaluated in quantity and quality. Results: A total of 299 laypersons were enrolled. 145 applicants in the LMAS (96.7%) and 143 in the LT (96%) group inserted the SAD in the right direction. Previous BLS education was not associated with a higher rate of success (LMAS (P=0.85) vs. LT (P=0.63)). The most common error identified was the depth of insertion (LT 40.9% (n=61) vs. LMAS 32.7% (n=49); P=0.18). No significant difference was found with regard to positioning the devices twisted or reversed (LT 4.7% (n=7) vs. LMAS 6% (n=9); P=0.79). Conclusion: In simulated setting laypersons can achieve appropriate skills and understanding for both SADs using a simple instruction manual. Application of SADs may be improved by a better labeling, the quality of the instruction sheet and a reduction in steps required.

https://www.longdom.org/open-access/following-onsite-instructions-for-operating-laryngeal-mask-a-randomized-trial-in-the-manikin-2155-6148.1000265.pdf

Following On-site Instructions for Operating Laryngeal Mask Supreme™ and Laryngeal Tube™ as an Alternative to Mouth-to-Mouth Ventilation in Layperson CPR: A Randomized Trial in the Manikin

Marlon Schwarz

Papers

Laypersons can successfully place supraglottic airways with 3 minutes of training. A comparison of four different devices in the manikin

The posterior dominant rhythm: an electroencephalographic biomarker for cognitive recovery after general anaesthesia.

Following On-site Instructions for Operating Laryngeal Mask Supreme™ and Laryngeal Tube™ as an Alternative to Mouth-to-Mouth Ventilation in Layperson CPR: A Randomized Trial in the Manikin