# King LT--quick question



## Bloom-IUEMT (Sep 6, 2009)

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:


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## emtbill (Sep 6, 2009)

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.


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## Akulahawk (Sep 6, 2009)

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...


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## Epi-do (Sep 6, 2009)

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.


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## Shishkabob (Sep 6, 2009)

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

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


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## 46Young (Sep 6, 2009)

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.


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## Akulahawk (Sep 6, 2009)

Linuss said:


> 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...)


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## 46Young (Sep 6, 2009)

Akulahawk said:


> 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.


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## Bloom-IUEMT (Sep 6, 2009)

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.


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## VentMedic (Sep 6, 2009)

Akulahawk said:


> 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.


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## ResTech (Sep 6, 2009)

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


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## Akulahawk (Sep 6, 2009)

VentMedic said:


> 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.


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## VentMedic (Sep 6, 2009)

Akulahawk said:


> 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.


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## Aidey (Sep 7, 2009)

Akulahawk said:


> 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.


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## Jon (Sep 7, 2009)

Linuss said:


> .... 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.


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## trevor1189 (Sep 10, 2009)

Akulahawk said:


> 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.


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## ki4mus (Sep 10, 2009)

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


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## Shishkabob (Sep 10, 2009)

ki4mus said:


> 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.


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## Akulahawk (Sep 10, 2009)

Linuss said:


> 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.


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## ki4mus (Sep 10, 2009)

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.


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## Shishkabob (Sep 10, 2009)

That's what I'm saying, Akula:  When you need an ETT, do an ETT, but you won't always need an ETT for every patient who needs more than an NPA/OPA.

An ETT is always the gold standard, but that doesn't mean everyone needs one.


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## 46Young (Sep 10, 2009)

IMO, if you're the only medic onscene and only have one EMT with you and no one else, it would be better to quickly drop the king (quick, easy, reasonably effective), so you could watch the monitor, establish an IV/IO, so on and so forth. The pt should be adequately oxygenated, and your hands are free to continue with other interventions. You have the added benefit of not inflating the pt's abdomen as much as the prep time prior to ETT placement. It doesn't take much more time to place a king than it takes to place an OPA. Pop on an ETCO2 before you start bagging.

Also, if a supraglottic airway is adequate for the pt's oxygenation at the moment, replacing that with an ETT in the field (medevac notwithstanding) is foolish, unneccesary, and dangerous for the pt.

Now, if you have a pt that codes in front of you, or is in imminent resp arrest (APE, tight asthmatic, etc) the ETT is the only appropriate first line procedure.

With arrests, the AHA has gone away from ETT's if BVM vents are effective. I figure that if you drop a king, you're ahead of the game with a fairly decent airway. Just have the basic bag and do compressions for the few seconds it takes you to place the king. Done.

Now, if you have two or more medics, ETT ought to be placed instead of a king.


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## Brandon O (Sep 10, 2009)

All things considered, what are the advantages of an ETT over a King or combi?


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## Shishkabob (Sep 10, 2009)

When placed correctly, definitive airway past the epiglottis, and a direct route for drugs.


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## Akulahawk (Sep 10, 2009)

Linuss said:


> That's what I'm saying, Akula:  When you need an ETT, do an ETT, but you won't always need an ETT for every patient who needs more than an NPA/OPA.
> 
> An ETT is always the gold standard, but that doesn't mean everyone needs one.


My standard has been that if someone needs an OPA, they need a tube. Not everyone needs an OPA... and not everyone needs to have an airway adjunct placed... but when they do, they DO. It's tempting to drop a rescue airway, but those don't address blocked airways, other than the tongue.

The other reason I choose ETI over a rescue airway is that I'd have both a secure airway and a route of drug admin (not great, but useful)... I'd prefer an IV for drug admin, but...


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## VentMedic (Sep 10, 2009)

Brandon Oto said:


> All things considered, what are the advantages of an ETT over a King or combi?


 
You can put the patient on a ventilator with an ETT.  You can not with a King or Combitube in the esophagus.   It the Combitube does end up in the trachea, the patient can plan on damage to the vocal cords and probably a trach for awhile if not worse.


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## carpentw (Sep 11, 2009)

*I'll play devils advocate here...*

I think a rather large advantage to the "rescue" airways is the hypoxia factor associated with ETI.  With a king or LMA you can quickly secure an airway and move on to other issues, like ventilating the patient!  Additionally, if you have adult and pedi IO capabilities, you shouldn't need to be dumping medications down an ET tube.  I think dumping medications down an ET tube is archaic (personal opinion).  King airways and LMA supremes guard the airway extremely well against aspiration and allow easy access to decompress the stomach.  Several places are making ETI the rescue airway and LMAs or Kings the primary airway.  Overseas the JRCALC in England made a recommendation to make ETI the back up and LMAs primary.  The service I currently work for has implemented RSA instead of RSI.  We use an LMA supreme or King-LTSD as the primary choice for an airway and intubation as a backup.  The "Gold standard" of intubation is fading away.  Don't get me wrong though, I think intubation is still called for in certain circumstances and SHOULD NOT be removed as a skill, but do believe it should be a back up airway instead of a primary airway..


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## Brandon O (Sep 11, 2009)

So, the advantages of intubation are:

-- Remains patent even in cases of laryngeal edema, laryngospasm, etc
-- Provides a little-used but available route for drugs
-- PT can be hooked to a ventilator upon reaching definitive care without switching airways

Anything else?


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## ki4mus (Sep 12, 2009)

carpentw said:


> ...you shouldn't need to be dumping medications down an ET tube.  I think dumping medications down an ET tube is archaic (personal opinion)....



Meds down the tube present a few advantages, primaraly epi....where it dialates the airwayalmost imedatly upon exiting the tube, opening the airway from the airway intsead pf circulating though the blood....



"I know that probly didn't make much since....forgive me as I just finished the 50th hour of a 48 hour shift....."


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## VentMedic (Sep 12, 2009)

ki4mus said:


> Meds down the tube present a few advantages, primaraly epi....where it dialates the airwayalmost imedatly upon exiting the tube, opening the airway from the airway intsead pf circulating though the blood....


 
Not necessarily.  For effective dilation, particle size must be taken into consideration for the med to absorp.  Thus, the reason we don't just dump albuteral down a tube in its liquid form.


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## Akulahawk (Sep 12, 2009)

VentMedic said:


> Not necessarily.  For effective dilation, particle size must be taken into consideration for the med to absorp.  Thus, the reason we don't just dump albuteral down a tube in its liquid form.


Which is also why after you "dump" meds down the tube, you give the bag a few small, sharp squeezes... you might aerosolize those meds a bit and get them to work better. Ideal? Not a chance. Aerosolizing the meds as you bag them into the lungs would probably work better, but... the connection from ETT to Bag is pretty short, and not exactly ideal for attaching a nebulizer, though it would be doable... and it takes a nebulizer a while to deliver the med...

The extremely small droplet size you do get from a nebulizer does allow those droplets to get much further down the respiratory tree than say, 10 ml of medicated fluid... that's "blown" in after being dumped down the tube...


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## 46Young (Sep 12, 2009)

Akulahawk said:


> Which is also why after you "dump" meds down the tube, you give the bag a few small, sharp squeezes... you might aerosolize those meds a bit and get them to work better. Ideal? Not a chance. Aerosolizing the meds as you bag them into the lungs would probably work better, but... the connection from ETT to Bag is pretty short, and not exactly ideal for attaching a nebulizer, though it would be doable... and it takes a nebulizer a while to deliver the med...
> 
> The extremely small droplet size you do get from a nebulizer does allow those droplets to get much further down the respiratory tree than say, 10 ml of medicated fluid... that's "blown" in after being dumped down the tube...



We have in-line neb setups to give albuterol/atrovent to a pt that's on CPAP or one that's intubated, if needed. I don't know about nebulized arrest meds though.


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## Akulahawk (Sep 12, 2009)

46Young said:


> We have in-line neb setups to give albuterol/atrovent to a pt that's on CPAP or one that's intubated, if needed. I don't know about nebulized arrest meds though.


I've known about in-line nebs for a while... I just don't think that you can deliver code meds in-line fast enough for them to be useful in that situation. Perhaps in a pre-arrest situation...


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## VentMedic (Sep 12, 2009)

In line nebs have been common for ventilator patients for decades although now the preferred is the MDI but the new HFA propellant has been creating some issues (thank you Canadians :glare.   Bagging a treatment in is acceptable except one must remember the increased flow will increase the VT on kids and babies.  For vents and bagging, we may run a nebulizer designed for 2 L of flow.  Don't try this low flow with a standard acorn neb or you will get particles that are too large if any at all.   

We may also use the nebs capable of being powered by 2 L/M inline with a CPAP/BiPAP machine.   Giving nebs by BiPAP/CPAP has been controversial as the turbulent flow hampers deposition of the particles.  If there are vents on the face mask present, that also causes flow disturbance and much of the med to be lost as does an inline whisper valve.  Adding flow to the circuit from a neb also presents with a flow disturbance.   

However, the little prehospital  "CPAP" devices rarely have an issue of too much flow but there is not that much data to determine how effective nebs are through these devices.

Code meds would not absorb systemically fast enough if given through the lungs which is why they are no longer advocated in ACLS.  As well, the meds given by nebulization are meant to have an effect on specific receptors within the lungs to reduce side effects.    Over 30 years ago when research was being done for the ACLS meds, each was trialed through the pulmonary system.  Few proved effective. NaHCO2 was also trialed and although it was not proven effective for its intended purpose, it was found to have "snot busting" properties.  It is an active ingredient in some nasal sprays and I also carry it diluted on Neo/Pedi transports to unplug a clogged ETT quickly without the need to pull the tube.  I don't recommend that since it is off label unless your M.D. approves.  It can cause bronchospasm and damage to the tissue of the lungs if not used correctly.


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