King LT--quick question

[Bloom-IUEMT]

In my state we use the Combi-Tube so I'm not familiar with the King LT. If you insert the tube in the esophagus how do you manage to get air where it belongs? The Combi is a dual-lumen so you just switch the bag to the other external lumen but I noticed the King only has one lumen. :unsure:

 

[emtbill]

Both of the devices are intended to be places in the esophagus. The way both devices work is to have cuffs at the distal and proximal ends of the tube. If the device is placed in the esophagus, air is blocked from entering the stomach by the distal cuff, and blocked from exiting the oropharynx by the proximal cuff. There is only one other place for it to go, the trachea. The King tube is designed to make intubating the trachea nearly impossible due to its short shape and bendable material. The combitube has a second lumen with a hole at the distal end for use in the event that the trachea is intubated, but most of the time it is placed in the esophagus and works as described above.

 

[Akulahawk]

The King Tube is basically a combitube that isn't designed to go into the trachea. It has two cuffs like the combitube. Like the combitube, when the esophagus is intubated, you're going to be unable to deliver meds down the tube...

Here's a picture of what I found...

Here's a pic of how they work...

Much like a combitube... for the 80% of the time that results in an esophageal intubation...

 

[Epi-do]

Just wanted to let you know that it is dependent upon the service/area you work in Indiana as to whether you carry Kings or combis. I am on the east side of Marion County and we carry Kings on our trucks.

 

[Shishkabob]

As has been stated, the King is designed to NEVER make it into the trachea.

Works very well, very simple, amd almost idiot proof.

 

[46Young]

We went to King's here as a backup for failed intubation attempts in lieu of a combitube. Actually, when working an arrest, it might not be a bad idea to have a qualified basic (assuming you have multiple responders working the job) drop a King while you get an IV/IO, and worry about dropping an ETT (only if still needed) after getting the first round of meds/electrical therapy onboard.

Actually, if you drop a King and an EZ-IO, you can get the ball rolling in record time. Add an autopulse, Res-Q-Pod, and ETCO2 monitoring, and you're absolutely dialed. We're also getting the Phillips monitors that have that thing that goes on the chest that measures the rate/depth of Cx compressions, with voice feedback to keep you on task.

 

[Akulahawk]

As has been stated, the King is designed to NEVER make it into the trachea.

Works very well, very simple, and almost idiot proof.

And NEVER forget that you might end up partnered with a new and improved idiot model... :blink:

I also noted that at least one model can be used for intubation.... but it'll require a 6.0 mm ETT. Apparently, that King Tube model essentially aims the ETT, as it could function as an introducer where the ETT slides inside the King Tube. This makes me wonder if it's possible to secure an airway with a King Tube, and later introduce a Bougie, remove the KT, and then slide an appropriately sized ETT over the Bougie and into the trachea. (probably not an original idea...)

 

[46Young]

And NEVER forget that you might end up partnered with a new and improved idiot model... :blink:

I also noted that at least one model can be used for intubation.... but it'll require a 6.0 mm ETT. Apparently, that King Tube model essentially aims the ETT, as it could function as an introducer where the ETT slides inside the King Tube. This makes me wonder if it's possible to secure an airway with a King Tube, and later introduce a Bougie, remove the KT, and then slide an appropriately sized ETT over the Bougie and into the trachea. (probably not an original idea...)

Not a bad idea. I'll bring this up with my medical director.

 

[Bloom-IUEMT]

Thanks for the clarification. I came across an article that demonstrated KLT tubes are much quicker than Combis
http://www.jems.com/news_and_articles/columns/Wesley/flight_crew_use_of_king_lt_versus_combitube.html;jsessionid=2CC7654DD698CEB78999610F1846ECC4 and was curious as to why our service didn't use them. They do seem "idiot proof."

Epi-do: I assumed it was a state protocol because its on the state practical. I have a bad habit of assuming things and it ends up biting me in the a** especially when I'm working.

 

[VentMedic]

And NEVER forget that you might end up partnered with a new and improved idiot model... :blink:

I also noted that at least one model can be used for intubation.... but it'll require a 6.0 mm ETT. Apparently, that King Tube model essentially aims the ETT, as it could function as an introducer where the ETT slides inside the King Tube. This makes me wonder if it's possible to secure an airway with a King Tube, and later introduce a Bougie, remove the KT, and then slide an appropriately sized ETT over the Bougie and into the trachea. (probably not an original idea...)

I have used a bougie a few times when removing the King in the ED although we usually have a fiber optic scope handy if there is evidence of bleeding/trauma although that is more common with the Combitube. Luckily (?), very few patients survive who have a Combitube to where ETI will be needed as most of these codes are called shortly after arrival to the ED. Those that do look like we might gain ROSC will need the tubes changed as will those who have inadequate ventilation. Those are a pain to change due to the tissue damage and air that has inflated the belly (aspiration) by poor placement and bagging to see which tube is in. We have ramped up our available intubating technology in the ED with the increased use of the supraglottic. Back when ETI was still a popular and well performed skill, most of the time all I needed was a tube changer to assist in inserting one of the hospital's ETTs.

If you are considering the removal of a device that is working in the field before you reach the hospital, you will want to consider the risks carefully. The supraglottic devices can cause just enough irritation, especially if inserted in less than ideal situations by people who are not well trained in their use, that may make ETI difficult.

If ROSC is obtained, a 6.0 mm will not be adequate to maintain an adult of average size on a ventilator for very long and will also have to be changed. Even in a very small slight built adult, a 6.5 mm is at the bottom limit of effectiveness. Of course in EMS one may have to do whatever for an airway.

 

[ResTech]

Another nice thing about the King airways is that they are latex-free. The Combitubes are not.

 

[Akulahawk]

I have used a bougie a few times when removing the King in the ED although we usually have a fiber optic scope handy if there is evidence of bleeding/trauma although that is more common with the Combitube. Luckily (?), very few patients survive who have a Combitube to where ETI will be needed as most of these codes are called shortly after arrival to the ED. Those that do look like we might gain ROSC will need the tubes changed as will those who have inadequate ventilation. Those are a pain to change due to the tissue damage and air that has inflated the belly (aspiration) by poor placement and bagging to see which tube is in. We have ramped up our available intubating technology in the ED with the increased use of the supraglottic. Back when ETI was still a popular and well performed skill, most of the time all I needed was a tube changer to assist in inserting one of the hospital's ETTs.

If you are considering the removal of a device that is working in the field before you reach the hospital, you will want to consider the risks carefully. The supraglottic devices can cause just enough irritation, especially if inserted in less than ideal situations by people who are not well trained in their use, that may make ETI difficult.

If ROSC is obtained, a 6.0 mm will not be adequate to maintain an adult of average size on a ventilator for very long and will also have to be changed. Even in a very small slight built adult, a 6.5 mm is at the bottom limit of effectiveness. Of course in EMS one may have to do whatever for an airway.

I don't think I indicated that I particularly approved of a 6.0 tube... just that it was what the KT would allow intubation with. If I've got an airway device in that allows me to ventilate the patient well, I'm going to keep that one in place, unless something changes that drives a decision to change to another airway device in a less than ideal situation.

Personally, I rather like the perspective you bring to this forum... especially as it pertains to ED/in-hospital use and change-out of these devices.

 

[VentMedic]

Personally, I rather like the perspective you bring to this forum... especially as it pertains to ED/in-hospital use and change-out of these devices.

I also have to make these decisions doing HEMS. If Rescue has already established a supraglottic device, rarely will we pull it unless we are not giving adequate ventilation.

As well, dealing with supraglottic device issues have been around over 30 years with the EOA and the EGTAs. Often we did have to change those before we moved the patient to the helicopter and it was not always pretty.

Working in the hospital while working EMS opened my eyes to doing things carefully and not doing things just because I could. I was able to see where every action can have a reaction or consequences even if it is considered a "save" by those in EMS.

 

[Aidey]

I also noted that at least one model can be used for intubation.... but it'll require a 6.0 mm ETT. Apparently, that King Tube model essentially aims the ETT, as it could function as an introducer where the ETT slides inside the King Tube. This makes me wonder if it's possible to secure an airway with a King Tube, and later introduce a Bougie, remove the KT, and then slide an appropriately sized ETT over the Bougie and into the trachea. (probably not an original idea...)

Per the King Airway Rep who did our training, they are designed with exactaly that in mind.

A big thing with the Kings is that there are two versions for adults. One with a gastric tube guide and one without. On the one with the gastric tube guide if you don't have a suction tube in, and you don't plug the hole the pt WILL regurgitate though the hole! One of our ED docs has been sprayed twice this way. The first time was an accident but the second time, he wasn't thinking and took the cap off himself.

 

[Jon]

.... Works very well, very simple, amd almost idiot proof.

ALMOST idiot proof. They always manage to build a better idiot.

I've never had a problem using one, the one time I had to.

 

[trevor1189]

And NEVER forget that you might end up partnered with a new and improved idiot model... :blink:

I also noted that at least one model can be used for intubation.... but it'll require a 6.0 mm ETT. Apparently, that King Tube model essentially aims the ETT, as it could function as an introducer where the ETT slides inside the King Tube. This makes me wonder if it's possible to secure an airway with a King Tube, and later introduce a Bougie, remove the KT, and then slide an appropriately sized ETT over the Bougie and into the trachea. (probably not an original idea...)

Believe I have seen that demonstrated in a video on youtube. If you have the time search for it.

 

[ki4mus]

As far as idiot proof goes, I have twice seen them literaly shoot out of a Pt's airway. And quite frankly I see this as a part of what seems to be a larger effort to remove yet another skill (ET) away from paramedics. a couple times I've heard that the King-LT is "better" than Endo-treachial intubation....HOW?!? How can a tube in the esophagus be better than one that is placed in the airway? I will tell you LAZY MEDIC sendrome and people not doing their job! If you watch the tube pass through the cords and secure it properly there is NO WAY that a King is better.(yes I know it can become displaced, but you check placment at regular intervals) As far as I am concered the King is no diferant than a Combitube, a last resort before surgical intervention for ALS and a good airway BLS

 

[Shishkabob]

As far as I am concered the King is no diferant than a Combitube, a last resort before surgical intervention for ALS and a good airway BLS

Why a last resort? The King and the Combi should be done before ETT so long as an ETT isn't required.

 

[Akulahawk]

Why a last resort? The King and the Combi should be done before ETT so long as an ETT isn't required.

The King and Combitube devices are rescue airways. If someone is obtunded enough to take either... guess what? They're obtunded enough for ETI. I would much rather have a device that secures that airway, no matter WHAT comes back up the esophagus. If I can't get the tube quickly, I'd better have a back up option or two.

Also, something else to remember: while efficacy of drugs delivered down the tube may or may not be all that good, the efficacy of drugs delivered down the King Tube or down the Combitube (for those 80% of the time esophageal intubations) is zero. At least with a Combitube, you have *A* chance at getting a tracheal intubation about 20% of the time... at which time it will function just as a regular ETT will.

 

[ki4mus]

Thank you Akulahawk. I agree with your post completly.

If the Pt needs a King and the Combi that means that their airway is compramised or soon will be. If this happens then they needed to be intubated. If they are not yet bad enough for a ET tube then an OPA or NPA would be suficant.