# King vs. Intubation



## VirginiaEMT (Aug 6, 2012)

If you were called to assist another squad with a working code and they had inserted a King airway before your arrival, what questions would you ask yourself to determine if you would remove the King and intubate the patient? I had this scenario not long ago and I left the King in because the airway was messy and I didn't want to take a chance of taking the King out and not being able to secure a patent airway again, but some others have told me they would have removed the King and intubated the patient. What would you do? And why?


----------



## Christopher (Aug 6, 2012)

VirginiaEMT said:


> If you were called to assist another squad with a working code and they had inserted a King airway before your arrival, what questions would you ask yourself to determine if you would remove the King and intubate the patient? I had this scenario not long ago and I left the King in because the airway was messy and I didn't want to take a chance of taking the King out and not being able to secure a patent airway again, but some others have told me they would have removed the King and intubated the patient. What would you do? And why?



If auscultation and waveform capnography showed a patent and adequately managed airway any preexisting airway will remain in-place.

If we use post-arrest induce hypothermia, we may elect to swap out the King to save time in the ED. I likely would not.


----------



## DrankTheKoolaid (Aug 6, 2012)

*re*

Depends on the way the resuscitation was going.  If I felt it was viable patient with a good chance at ROSC then yes, I would swap it out.  At this point in medicine every field code, make that every code in and out of hospital should be guided by EtCO2.  While this I believe can be done with a King in place im not 100% sure on it's accuracy.  Also if you read the latest literature and follow studies, King Airways have been shown to reduce neurological outcomes in patients.  May have saved the heart but the brain to a hit in the process. 

Google-Fu King airway Porcine studies for more info

So yes in most circumstances I would be swapping it to the definitive ETT.


----------



## Christopher (Aug 6, 2012)

Corky said:


> While this I believe can be done with a King in place im not 100% sure on it's accuracy.



There is no significant difference with EtCO2 readings from supraglottic airways and ETT, when an adequate bulb seal is present. I could pull some strips, but every time I've done/seen a swap the EtCO2 remains the "same" (probably +-3mmHg, not enough to notice).

The porcine studies have some interesting A&P questions related to the carotids, but are fundamentally sound. We likely should be evaluating the appropriate cuff inflation volumes when using King's.

Recently, Dr. Fowler has alluded to ROC data showing differences in discharge with ETT vs SGA, but focusing on just that comparison is a bit unfair. Simple BVM management showed a higher survival to discharge than *both ETT and SGA*. If you're going to use those studies, you shouldn't be placing an airway at all


----------



## VirginiaEMT (Aug 6, 2012)

Corky said:


> Depends on the way the resuscitation was going.  If I felt it was viable patient with a good chance at ROSC then yes, I would swap it out.  At this point in medicine every field code, make that every code in and out of hospital should be guided by EtCO2.  While this I believe can be done with a King in place im not 100% sure on it's accuracy.  Also if you read the latest literature and follow studies, King Airways have been shown to reduce neurological outcomes in patients.  May have saved the heart but the brain to a hit in the process.
> 
> Google-Fu King airway Porcine studies for more info
> 
> So yes in most circumstances I would be swapping it to the definitive ETT.



I had  great ETCO2 during the code so that is one of the reasons I decided not to remove it but the E.R doctor showed me an Xray and she definitely had vomitus in her lungs.


----------



## Christopher (Aug 6, 2012)

VirginiaEMT said:


> I had  great ETCO2 during the code so that is one of the reasons I decided not to remove it but the E.R doctor showed me an Xray and she definitely had vomitus in her lungs.



Likely this was present prior to your arrival and placement of the King.


----------



## DrankTheKoolaid (Aug 6, 2012)

*re*

Very true Christopher.   Will be interesting to see the final outcome of the French study.  I personally wont use Kings until the dust has settled and final word is spoken on the studies.  Just not worth risking a poor outcome if a ETT could have been placed just as fast.  Im never in that much of a hurry that i cant take 45s to a minute to set up and intubate someone instead of putting them at risk with a King. Yes BVM is definately a viable option, but again offers no protection.

Thats the other downfall to the King VirginiaEMT.  It does not offer the same airway protection that a ETT will.


----------



## Aidey (Aug 6, 2012)

I've done both, it depends on the situation. If we have good ventilation and capnography numbers I will lave it. I did exchange on a few months ago on a code that we were planning on calling. It was a younger female and the airway turned into a bloody mess (literally, not the British slang type of bloody). We swapped out the king for an ET tube because we knew if we were going to call someone as young as that pt was we needed a 110% for sure airway before the doc would agree.


----------



## socalmedic (Aug 6, 2012)

Christopher said:


> Recently, Dr. Fowler has alluded to ROC data showing differences in discharge with ETT vs SGA, but focusing on just that comparison is a bit unfair. Simple BVM management showed a higher survival to discharge than *both ETT and SGA*. If you're going to use those studies, you shouldn't be placing an airway at all



which is why it is completely acceptable to work a code with a BLS airway up until the point when/if you are going to transport. I have been argueing here against KING tubes because my county was on of the ROC countys that first showed a 50% decrease in rosc patients with a CPS score greater that 3.

I discourage anyone from using a king first line. as response to the OP I would have asked why a king was used, was it a difficult airway? I would have either gone back to BLS with a BVM/OPA or would have switched to ETI.


----------



## VirginiaEMT (Aug 6, 2012)

socalmedic said:


> which is why it is completely acceptable to work a code with a BLS airway up until the point when/if you are going to transport. I have been argueing here against KING tubes because my county was on of the ROC countys that first showed a 50% decrease in rosc patients with a CPS score greater that 3.
> 
> I discourage anyone from using a king first line. as response to the OP I would have asked why a king was used, was it a difficult airway? I would have either gone back to BLS with a BVM/OPA or would have switched to ETI.



The King was used because the crew on scene was BLS only and that is part of our local protocol for EMT-Bs and EMT-Es. We were called to respond medic level to assist a completely different agency. It was me and a paramedic. We are in rural Virginia and paramedics and EMT-I/99s are not in abundance at most rural agencies in our area.


----------



## jroyster06 (Aug 6, 2012)

We have started using the king tube as front line in an arrest situation recently. Since then i have had more messed up traumatized airway was filled with blood vomitus and who knows what that are red and puffy swollen. I have also had to use a lot more suction and all around have had more complications since then. Im not sure if its just a coincidence or if the king airway is the culprit.  Has anyone else noticed this?


----------



## LearningByMistakes (Aug 6, 2012)

When dealing with the airway it should be about ventilation NOT intubation.  If I arrive & the patient is being properly ventilated, there is NO need to change anything.


----------



## usalsfyre (Aug 6, 2012)

Unless you are VERY comfortable with your airway management I would caution you about pulling a working airway. Ending up with a cric because you don't like supraglotic airways is poor form...


----------



## DrankTheKoolaid (Aug 6, 2012)

LearningByMistakes said:


> When dealing with the airway it should be about ventilation NOT intubation.  If I arrive & the patient is being properly ventilated, there is NO need to change anything.



While that is a true statement we always have to be proactive and thinking ahead.  What good is a resus that dies of SIRS/Aspiration post code because a BLS airway was maintained and the airway was not protected.  It's not, it is simply a drain on resources and a emotional roller coaster for the poor stiff's family.

Take a look at it from a in-hospital perspective.  What is standard of care?  I can tell ya in the 20 years ive been doing this I can count on 1 hand how many times I have been in on codes in the ED that were not intubated.  Why do you think that is?  Do you think a ICU would except a post-code resus and just leave a King in place, or a BLS airway to maintain itself? 

Sure if you are not skilled enough to intubate through ventilations, then stick with a BLS/SGA as compressions are key.  But if you can get the airway protected which in the end will hopefully prevent a early demise from post code complications then by all means get that airway protected.


----------



## jwk (Aug 6, 2012)

usalsfyre said:


> Unless you are VERY comfortable with your airway management I would caution you about pulling a working airway. Ending up with a cric because you don't like supraglotic airways is poor form...



This!


----------



## LearningByMistakes (Aug 6, 2012)

Well Corky, I will tell you that from the 32 years that I have been doing this, that I have seen far too many times that a providers "EGO" ruled in getting a patient intubated, at the cost of what is best for the patient. I have also seen far too many patients that aspirated from the intubation attempt (including in many ERs), which most likely wouldn't have happened without the intubation attempt. 

And in Cardiac Arrest most studies have shown that intubation does little more than result in the stopping of CPR (many times for many minutes), when CPR is what IS important during the arrest (along with Defib, the ONLY 2 things that result in increased survival). 

Other then the occasional arrest secondary from hypoxia, intubation is NOT what resuscitates cardiac arrest, high quality uninterrupted CPR & Defib IS.

Airway should be about ventilation NOT intubation.

Now, once we get to post resuscitation, that’s a WHOLE new story.


----------



## usalsfyre (Aug 6, 2012)

Corky said:


> While that is a true statement we always have to be proactive and thinking ahead.  What good is a resus that dies of SIRS/Aspiration post code because a BLS airway was maintained and the airway was not protected.  It's not, it is simply a drain on resources and a emotional roller coaster for the poor stiff's family.
> 
> Take a look at it from a in-hospital perspective.  What is standard of care?  I can tell ya in the 20 years ive been doing this I can count on 1 hand how many times I have been in on codes in the ED that were not intubated.  Why do you think that is?  Do you think a ICU would except a post-code resus and just leave a King in place, or a BLS airway to maintain itself?
> 
> Sure if you are not skilled enough to intubate through ventilations, then stick with a BLS/SGA as compressions are key.  But if you can get the airway protected which in the end will hopefully prevent a early demise from post code complications then by all means get that airway protected.



Corky, it's a question of hands, light, devices and knowledge. Me pulling what is my rescue device to attempt a more difficult airway in relatively uncontrolled conditions with no back up is a questionable decision.


----------



## DrankTheKoolaid (Aug 6, 2012)

*re*

Learning, you obviously did not read my whole post as I plainly stated if your not skilled enough to get the tube then stick with a BLS airway.

US, Yeah I get that.  Obviously nobody in their right mind is going to pull a BLS airway that is working on someone with a airway nightmare.  

I just dont like blanket statements that BLS/SGA is best for codes.  They are temporizing measures until a definitive airway can be placed, assuming ROSC.


----------



## Aidey (Aug 6, 2012)

Aidey said:


> I've done both, it depends on the situation. If we have good ventilation and capnography numbers I will lave it. I did exchange on a few months ago on a code that we were planning on calling. It was a younger female and the airway turned into a bloody mess (literally, not the British slang type of bloody). We swapped out the king for an ET tube because we knew if we were going to call someone as young as that pt was we needed a 110% for sure airway before the doc would agree.





Corky said:


> US, Yeah I get that.  Obviously nobody in their right mind is going to pull a BLS airway that is working on someone with a airway nightmare.



Careful there. If there is reason to believe that the BLS airway is causing the airway nightmare pulling it can be the right thing to do.


----------



## Christopher (Aug 6, 2012)

Corky said:


> What good is a resus that dies of SIRS/Aspiration post code because a BLS airway was maintained and the airway was not protected.



You're correct that pneumonia is a common problem in the post-cardiac arrest patient: "Pneumonia caused by aspiration or mechanical ventilation is probably the most important complication in comatose post-cardiac arrest patients, occurring in up to 50% of patients after out-of-hospital cardiac arrest." (PubMed)

But, I don't believe the literature supports the claim than an ETT decreases the incidence of aspiration pneumonia post-ROSC: "Where the patient was ventilated with the BVM alone or BVM followed by ETT the incidence of regurgitation during CPR was 12.4%...Where the patient was ventilated with the LMA alone or LMA followed by ETT the incidence of regurgitation during CPR was 3.5%." (PubMed)

If you'll allow me to point to patients being RSI'd, I think they represent a similar cohort for patients receiving prehospital airway management during cardiac arrest: i.e. NPO status questionable. I would understand if you take exception to this connection, as I can't show the two groups are truly matched.

From a cohort of patients being RSI'd: "The vast majority of aspiration events seem to occur before the arrival of prehospital personnel." (PubMed)

This probably means that even if we do tube them, we're not going to prevent aspiration, and studies concur: "Paramedic RSI did not seem to prevent aspiration pneumonia." (PubMed)

Worse still, it seems regurgitation and aspiration may be associated with ETI attempts themselves! Of patients being intubated in the ED who experienced cardiac arrest it was found that, "twenty-seven patients (45%) suffered gastric contents regurgitation with concomitant hypoxemia during the event, a finding that was considerably higher than the matched cohort and the entire database. Of the regurgitation cases, 72% were associated with multiple esophageal intubations. All but three regurgitation cases were associated with esophageal intubation." (PubMed)

The data from ROC shows that ETI is at best at equivalent w.r.t. "Airway and Pulmonary Complications" with an OR of 0.84[0.61-1.16] (PubMed).

The problem appears to be that a large number (power unknown) of our patients in cardiac arrest have already aspirated. Careful attention to proper airway management to prevent further aspiration is important. While there may be a theoretical advantaged to prehospital placement of at ETT _to protect against aspiration_, there is no data to support this claim.


----------



## DrankTheKoolaid (Aug 6, 2012)

Aidey said:


> Careful there. If there is reason to believe that the BLS airway is causing the airway nightmare pulling it can be the right thing to do.



Yeah I actually thought that was obvious. If an airway is not patent with a BLS/SGA in place it gets pulled as it is not doing any good anyways and most likely was hastily placed and not sized correctly.

I was actually speaking about anatomical airway nightmares.


----------



## LearningByMistakes (Aug 6, 2012)

Obviously you did not read my post Corky. 

And are you questioning my ability to handle an airway? 

Christopher, well said.


----------



## DrankTheKoolaid (Aug 6, 2012)

*re*

?,  I am not singling any provider out.  Everyone knows there own competence level and should not go beyond it.  If any of my posts were mistakenly taken that way, it was done in error.


----------



## LearningByMistakes (Aug 6, 2012)

No problem then Corky, fair enough.


----------



## DrankTheKoolaid (Aug 6, 2012)

Their, There, They're 

I really hate when I miss that after the edit timer expires


----------



## LearningByMistakes (Aug 6, 2012)

LOL! Welcome to MY world Corky!


----------



## MSDeltaFlt (Aug 6, 2012)

What is an "airway"?  Definition: an unobstructed path between the oxygen source and the lungs.  Period. Without question. 

And what does A.H.A. suggest should be done for advanced airway placement during cardiopulmonary arrest situations?  Simple. Don't stop compressions. What if the airway is a Grade 4?  Don't stop compressions.  

So what should be done when a higher level of care arrives on scene?  

1. Breathe. Even if your pt isn't, you make d@MN sure you do.  

2.  Never say never. Never say always.  

3.  Assess the situation: history of the call and especially the pt. Not merely some @#$% EtCO2. Assess the airway: patency, ventilation (breath sounds AND EtCO2).

Then do what's right.

Would I have changed the King?  Depends. Depends on what I Would discover in what I typed in the above.


----------



## lightsandsirens5 (Aug 7, 2012)

usalsfyre said:


> Unless you are VERY comfortable with your airway management I would caution you about pulling a working airway. Ending up with a cric because you don't like supraglotic airways is poor form...



Well, usals beat me to it. As usual.


----------



## Sublime (Oct 10, 2012)

Sorry for bringing this thread back from the dead, but I have some questions!
I'm a new primary medic at my service and in our protocols we have the option to intubate or use a king in an arrest. In a full arrest situation it says a king is preferred over ETT due to ease of placement and not having to interrupt compressions. 

I know intubation is the standard in the hospital, but what advantages does it have over the king? The king occludes the esophagus and even has a gastric port so you can suction to further prevent aspiration. If there is a proper bulb seal I really don't see why it's regarded as inferior in this manner.

Obviously the ET tube is directly in the trachea and the king is a supraglottic airway, but if you're getting good chest rise and capno then what's the difference? Why would changing even be considered?


----------



## Aidey (Oct 10, 2012)

I don't know if it was in this thread or not, but there have been concerns raised about neurological outcomes in pts who had a king placed. The current theory is that they place too much pressure on the internal carotid arteries causing decreased blood flow to the brain.


----------



## Medic Tim (Oct 10, 2012)

Sublime said:


> Sorry for bringing this thread back from the dead, but I have some questions!
> I'm a new primary medic at my service and in our protocols we have the option to intubate or use a king in an arrest. In a full arrest situation it says a king is preferred over ETT due to ease of placement and not having to interrupt compressions.
> 
> I know intubation is the standard in the hospital, but what advantages does it have over the king? The king occludes the esophagus and even has a gastric port so you can suction to further prevent aspiration. If there is a proper bulb seal I really don't see why it's regarded as inferior in this manner.
> ...



There is newer evidence out against the king airs showing ETI and bls airway leads to better pt outcomes in an arrest (at work on my phone so I don't have a link) and Not all of them have the port on the back for a ng/og tube.


----------



## d_miracle36 (Oct 10, 2012)

I believe that ETI is the golden standard and will remain although a bls airway may lead to better outcomes I think the outcomes are probably more provider error than it is the actual airway. Isnt the king a bls airway?


----------



## VirginiaEMT (Oct 10, 2012)

Medic Tim said:


> There is newer evidence out against the king airs showing ETI and bls airway leads to better pt outcomes in an arrest (at work on my phone so I don't have a link) and Not all of them have the port on the back for a ng/og tube.



There's tons of evidence that ETI is detremental to patient outcomes after cardiac arrest. I just finished a paper on the studies for paramedic school.


----------



## Aidey (Oct 10, 2012)

Just because ETI can be detrimental doesn't mean that a king can't be more detrimental.


----------



## d_miracle36 (Oct 10, 2012)

I love the kings and lmas. A ETT can be detrimental when compressions are interrupted and verification has failed. The patient does not care what airway is in place as long as they are getting oxygen to the brain. Proper intubation is as good as king airway placement. Failure to intubate is not what kills people its failure to ventilate. Provider preference is key. If a skilled paramedic intubates it is as good if not better than a king airway placement. The problem is that there is a lack of skilled paramedics. ETI with monitored etco2 is the same as king airway with monitored etco2.


----------



## Aidey (Oct 10, 2012)

d_miracle36 said:


> I love the kings and lmas. A ETT can be detrimental when compressions are interrupted and verification has failed. The patient does not care what airway is in place as long as they are getting oxygen to the brain. Proper intubation is as good as king airway placement. Failure to intubate is not what kills people its failure to ventilate. Provider preference is key. If a skilled paramedic intubates it is as good if not better than a king airway placement. The problem is that there is a lack of skilled paramedics. *ETI with monitored etco2 is the same as king airway with monitored etco2.*


----------



## d_miracle36 (Oct 10, 2012)

Sorry I was speaking from experience. In my opinion expired gas should be the same regardless of the device its coming from if positioned properly. I dont think there is any data showing and or proving the effectiveness of using ETCO2 with a king or lma. Is it not widely accepted to use etco2 with blind insertion devices? And if it is not accepted then how many people wrongly guide their treatment based upon those values?


----------



## d_miracle36 (Oct 10, 2012)

Christopher said:


> There is no significant difference with EtCO2 readings from supraglottic airways and ETT, when an adequate bulb seal is present. I could pull some strips, but every time I've done/seen a swap the EtCO2 remains the "same" (probably +-3mmHg, not enough to notice).
> 
> The porcine studies have some interesting A&P questions related to the carotids, but are fundamentally sound. We likely should be evaluating the appropriate cuff inflation volumes when using King's.
> 
> Recently, Dr. Fowler has alluded to ROC data showing differences in discharge with ETT vs SGA, but focusing on just that comparison is a bit unfair. Simple BVM management showed a higher survival to discharge than *both ETT and SGA*. If you're going to use those studies, you shouldn't be placing an airway at all


...


----------



## usalsfyre (Oct 10, 2012)

d_miracle36 said:


> I love the kings and lmas. A ETT can be detrimental when compressions are interrupted and verification has failed. The patient does not care what airway is in place as long as they are getting oxygen to the brain. Proper intubation is as good as king airway placement. Failure to intubate is not what kills people its failure to ventilate. Provider preference is key. If a skilled paramedic intubates it is as good if not better than a king airway placement. The problem is that there is a lack of skilled paramedics. ETI with monitored etco2 is the same as king airway with monitored etco2.



What your arguing is that poor ETI is worse than good King placement, without really addressing good ETI, or bad work with a King. 

Further, recent research (ROC PRIMED) suggest that the patient DOES care how ventilations are delivered (the author I spoke with mentioned 50% worse outcomes with a King vs ETI) but we're not entirely sure why.


----------



## Aidey (Oct 10, 2012)

The question isn't whether EtCo2 works with both ETI and Kings, the question is if they are the same. Yes, there have been studies done that show basic airway maintenance is better that either ETI or a King. Not to repeat myself, but just because ETI can be detrimental to outcomes doesn't mean the king can't be more detrimental.


----------



## d_miracle36 (Oct 10, 2012)

usalsfyre said:


> What your arguing is that poor ETI is worse than good King placement, without really addressing good ETI, or bad work with a King.
> 
> Further, recent research (ROC PRIMED) suggest that the patient DOES care how ventilations are delivered (the author I spoke with mentioned 50% worse outcomes with a King vs ETI) but we're not entirely sure why.



Yes poor ETI is worse than good king placement. Good ETI is of course better than than bad king placement and vice versa. 

In my opinion appropriate bvm ventilations would make a patient happy. Good ETI would make a patient happy and good King placement would make a patient happy.

Apparently in pigs SGA's impair carotid blood flow
http://www.ncbi.nlm.nih.gov/pubmed/22465807?dopt=AbstractPlus

And in some studies no ventilations at all lead to better outcomes
http://circ.ahajournals.org/content/116/22/2514.full

I dont think this alone will make me change my practice but may be something to look forward to in the future.


----------



## Shishkabob (Oct 10, 2012)

VirginiaEMT said:


> There's tons of evidence that ETI is detremental to patient outcomes after cardiac arrest. I just finished a paper on the studies for paramedic school.



And there's newer studies coming out saying just the opposite, that ETI is actually beneficial, and in some cases, Kings are bad.


Such is medicine, it will always go back and forth.


----------



## d_miracle36 (Oct 10, 2012)

Aidey said:


> The question isn't whether EtCo2 works with both ETI and Kings, the question is if they are the same. Yes, there have been studies done that show basic airway maintenance is better that either ETI or a King. Not to repeat myself, but just because ETI can be detrimental to outcomes doesn't mean the king can't be more detrimental.



Yes I agree with you 100% that both can be detrimental and the king may be more detrimental, I dont know. Does anyone?


----------



## Christopher (Oct 11, 2012)

Linuss said:


> And there's newer studies coming out saying just the opposite, that ETI is actually beneficial, and in some cases, Kings are bad.



That study also showed, but didn't highlight, that not using a King or ETT (or even never successfully establishing an advanced airway) was better.

Non-rebreather and an OPA for at least the first half the code!


----------



## MrJones (Oct 11, 2012)

Would it be possible to get links/citations for some of these studies that are being bandied about? I'd like to read up on some of them.

thx.


----------

