ET vs Laryngeal airway

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YarrikSeelight

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Your opinions about ET vs Laryngeal airway (LT, LMA, iGel) Do you think ET is better than laryngeal?

I'm not trained for ET use, but I want to hear your opinions why it's used as a primary airway management device over the laryngeal airways? All of the laryngeal airways has a pretty good seal to prevent aspiration, they are fairly easy to insert and they are fast and they can be inserted easily alone.

Why is ET used over them? ET requires multiple people (usually) it's slow and hard and you need to do laryngoscopy.

Any discussion about ET vs Laryngeal is allowed.

Thank you!
 
What's the context for your question? Are you curious about the use for a particular etiology?
 
I'm applying to paramedic school and have taken few courses already. I'm just curious why is ET used for airway management over other easier options. I would assume it's better somehow? But how?
 
The short answer is that supraglotic airways are probably just as good or better than intubation for the vast majority of patients in the field.

There are times in which intubation is more adventagious. You can provide much higher airway pressures through an ET tube than supraglotic airways (this is more relevant to ARDS patients in the unit). They are typically better at keeping patients from aspirating, although the new igels seem to be better than previous products and patients can still have secretions get past an ET cuff and develop a pneumonia. There are certain procedures that require intubation but these are typically performed in the OR or unit. I'm not sure if you can use oscillators or nitric with supraglotic airways, I've never seen it done.

We know that historically field intubations have a high failure rate. Multiple studies show that patients who had a supraglotic airway had better outcomes than those with intubation attempts.

My opinion is that intubation provides better airway control, and that we should be having medics spend more time in the OR practicing. This probably isn't a realistic option for the majority of medics/agencies, and favoring supraglotic airways will be a more beneficial treatment modality. I also have some bias in that when I started out option was to intubate or drop a combitube, and the majority of my intubations have been on kids which are much easier to tube than adults.

The real reason that ET tubes are favored in EMS is that a lot of medics have a lot of pride in dropping a tube. I think that there is a fear associated with saying that medics can't or shouldn't intubate, that there is some loss of identity or something associated with it.
 
YarrikSeelight said:
Your opinions about ET vs Laryngeal airway (LT, LMA, iGel) Do you think ET is better than laryngeal?
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An ET tube is, objectively speaking, a "better" airway when you think about things like aspiration risk and ability to provide higher airway pressures.

However, that is a different question than asking "which airway is better for prehospital use"?

YarrikSeelight said:
I'm not trained for ET use, but I want to hear your opinions why it's used as a primary airway management device over the laryngeal airways? All of the laryngeal airways has a pretty good seal to prevent aspiration, they are fairly easy to insert and they are fast and they can be inserted easily alone.
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To be honest, I don't know that supraglottic airways are definitely easier to place. Their advantage comes from the fact that you don't need to induce paralysis in order to place one. This confers several important advantages.

They don't provide as good a seal as an ET tube, but the newer ones do a pretty decent job or protecting the trachea and allowing for reasonable airway pressures.

The bottom line is that ET tubes are risker to place, and in most cases don't provide a lot of advantage over supraglottic airways in the prehospital setting.
 
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ET is a more "definitive" airway but it needs to put in right and kept in place in order to serve as definitive.
 
LMAs are easy to use, easy to teach, cheap, and do a pretty good job in most patients who need more than an oral or nasal airway.

Most ambulance personnel only put in a couple a year and all but one or two of those are probably in cardiac arrest. Some ambulance personnel are volunteers who might only put in one a year or less so it needs to be something you can do easily and have a low risk of anything going wrong. The LMA is great for that.

Intubation is difficult to master and you have to do lots and lots of it to keep up being good at it. I think i read somewhere or somebody told me the average anaesthetist does like 200 intubations a year; the average ICP does maybe one a month? Intubation is now thoroughly de-emphasised except in patients who are very unconscious with a poor airway that cannot be managed any other way.

The obvious exception here is rapid sequence intubation.
 
Remi said:
To be honest, I don't know that supraglottic airways are definitely easier to place. Their advantage comes from the fact that you don't need to induce paralysis in order to place one. This confers several important advantages.
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They are easier in the sense that you don't need to visualize the glottis, which is much of the challenge in intubation. I presume you're saying this is balanced by some other aspect of their use that's harder?
 
In a cardiac arrest, the SGA works just as good if not better, because insertion failure rates are lower than ET use.

However, what about for non-cardiac arrest? airway burns, RSI, airway obstruction, tracheal trauma, etc.

In most cases (cardiac arrest being the most common), the SGA will work fine. In the other cases, it won't do the job.
 
I agree with this. In cardiac arrest we attempt ET but typically end up with an alternate airway device due to the fact that in that specific situation, it works better. As for other cases, I junk it depends on protocol as to what you try first- ET or another device
 
Brandon O said:
They are easier in the sense that you don't need to visualize the glottis, which is much of the challenge in intubation. I presume you're saying this is balanced by some other aspect of their use that's harder?
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I don't have any objective evidence to back any of this up; it's just my opinion based on my own experience and what I've seen many other learners (primarily CRNA trainees, but also paramedic students, RRT's and others) deal with:

ETI and SGA placement both have a pretty short and flat learning curve to a very basic level of competence, by which I mean the ability to place the device properly and fairly expeditiously almost all of the time, in a patient or setting that doesn't offer any particular challenge. Incidentally, I think this is why quite a few people tend to overestimate their expertise in airway management.

Beyond mastering the basics of placement, I think the learning curve for SGA's actually gets a little steeper than ETI for a bit. At this intermediate point you can still visualize the glottis pretty easily on most patients, but you are dealing with patients whose anatomy may not be a perfect fit for SGA's. The SGA will still work, but it takes a little more "feel" to get a good seat; the skill isn't quite as objective as ETI. Again, I think this supports an inflated sense of competence with intubation among people who have only done it, say, a couple dozen times, and may be part of the reason why some people dislike SGA's.

After you surpass that intermediate level of proficiency, the SGA learning curve flattens right out while the ETI learning curve continues not steeply, but steadily upwards until you have done many intubations on many different types of patients.
 
Remi said:
I don't have any objective evidence to back any of this up; it's just my opinion based on my own experience and what I've seen many other learners (primarily CRNA trainees, but also paramedic students, RRT's and others) deal with:

ETI and SGA placement both have a pretty short and flat learning curve to a very basic level of competence, by which I mean the ability to place the device properly and fairly expeditiously almost all of the time, in a patient or setting that doesn't offer any particular challenge. Incidentally, I think this is why quite a few people tend to overestimate their expertise in airway management.

Beyond mastering the basics of placement, I think the learning curve for SGA's actually gets a little steeper than ETI for a bit. At this intermediate point you can still visualize the glottis pretty easily on most patients, but you are dealing with patients whose anatomy may not be a perfect fit for SGA's. The SGA will still work, but it takes a little more "feel" to get a good seat; the skill isn't quite as objective as ETI. Again, I think this supports an inflated sense of competence with intubation among people who have only done it, say, a couple dozen times, and may be part of the reason why some people dislike SGA's.

After you surpass that intermediate level of proficiency, the SGA learning curve flattens right out while the ETI learning curve continues not steeply, but steadily upwards until you have done many intubations on many different types of patients.
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Interesting. Would you say it's true, however, that when something like an LMA gives you trouble, you can often still ventilate through it to some degree (i.e. it remains a usable rescue airway), albeit imperfectly -- whereas when endotracheal intubation fails, it fails completely?
 
Brandon O said:
They are easier in the sense that you don't need to visualize the glottis, which is much of the challenge in intubation. I presume you're saying this is balanced by some other aspect of their use that's harder?
Click to expand...

A couple of years ago I was getting some tubes in the OR one of the anesthesiologists wanted me to place an LMA on a 200 plus kilo patient, which before actually placing it I thought was a bit of a waste of my time. Lesson learned. Especially if the patient hasn't received paralytics their jaw can have so much less mobility than we see in RSI or most arrested patients, and trying to cram that thing in around their surplus of neck/face just adds to the experience. It was honestly the most difficult airway to place that day.
 
Brandon O said:
Interesting. Would you say it's true, however, that when something like an LMA gives you trouble, you can often still ventilate through it to some degree (i.e. it remains a usable rescue airway), albeit imperfectly -- whereas when endotracheal intubation fails, it fails completely?
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Absolutely. At it's worst, an LMA is basically a not-working-very-well OPA.
 
Remi said:
Absolutely. At it's worst, an LMA is basically a not-working-very-well OPA.
Click to expand...

Well... one that doesn't require a mask seal.
 
ET is a secure airway, secure in the fact that they can’t aspirate. LMAs, Kings, and I-gels are not. That pretty much sums it up. I prefer ET it I’m doing an advanced airway but I also agree that it is not the best choice for every patient with a compromised airway. I like passive oxygenation for most arrests I run with the exception of pediatrics or with a suspected foreign body.
 
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