LMA vs ET tube

[fire_911medic]

At my place of employment we used to carry endotracheal tubes and combi-tubes. However, the combi-tubes were recently phased out in favor or the King LTs (BEST DECISION EVER). We also have nasogastric tubes to alleviate gastric distension. According to this study, the King LT has significant accuracy and placement time advantages over ETTs or Combi-tubes. However, as has been stated the endotracheal tube provides better protection... also, something I don't think anybody has touched on, the endotracheal tube, if correctly placed, gives us another route for certain medications, something the LMA, Combi-tube, and King LT doesn't.

That is defintely another benefit to the King - which I believe I mentioned earlier (perhaps I didn't brain is slow today) is the ability to use an NG tube to prevent gastric distention. I agree that the King is almost impossible to not place correctly and with the advantage of having multiple sizes (though the LMA does as well), it's going to provide better protection with less trauma if compared directly to the combi tube, though all being said, I've not seen an LMA cause much trauma at all. But I also have quite limited experience with them as when I had the first two go badly I steered away from them and towards the King LT.

Overal I think better assessment and early recognition of difficult airways and utilization of alternate devices like the King LT is going to help improve the situation (with the exception of excessive airway trauma which would require a more definitive airway)

Another thing to consider is with the widespread use of the IO's, meds down the tube is used less and less. You can find a site to put an IO in almost anyone and in all honesty, I would go that route over putting meds down the tube anyday. Remember any time meds go down the tube, you are putting on average double the dose - put enough down it while you are fishing around for a line and well, a few meds, a few rounds, and you have the potential of overloading the lungs with fluid. Just something to consider. It takes seconds to place an IO (especially with EZ IO) and in arrest situations, likelihood is that (with our response times) they will be peripherally clamped down and it's gonna be tough to get a line established anyway. I'm probably going to go IO anyways. Just another side of the fence...

Everybody take care and stay safe out there !

 

[phildo]

There are LMAs out now that facilitate ET placement going through an already placed LMA.

Those are really expensive. would love to have them.

 

[ivanh3]

The question should be decided based on patient outcomes. There is entirely to much "YMMV" in EMS already. Two recent articles suggest that the ET tube is not what it used to be. I have seen entirely too much time wasted on "gettin' the tube" during arrests. I have seen this both in the hospital and pre-hospital setting. I have literally stood at the door of the ER and watched crews still trying to intubate in the ambulance bays. Here are two recent articles about the subject. The one by Bledsoe and Gandy published in the March 2009 addition of JEMS is probably well known here. The other is an article from the AAP.

http://www.jems.com/news_and_articles/articles/jems/3403/the_disappearing_endotracheal_tube.html

http://pediatrics.aappublications.org/cgi/content/full/122/2/e294

 

[rhan101277]

Also LMA's tend not to stay in place as most ambulance rides are very bumpy, where as you can count on your ET tube.

Also you can't use LMA's or combitubes on pediatric patients or folks under 5 feet tall.

 

[8jimi8]

Also LMA's tend not to stay in place as most ambulance rides are very bumpy, where as you can count on your ET tube.

Also you can't use LMA's or combitubes on pediatric patients or folks under 5 feet tall.

Don't "count" on your tube. Verify and RE-verify your placement. The one time you don't may have been the wrong one to trust. The ambulance IS very bumpy and ET tubes DO migrate.

 

[ivanh3]

Also LMA's tend not to stay in place as most ambulance rides are very bumpy, where as you can count on your ET tube.QUOTE]

Don't "count" on your tube. Verify and RE-verify your placement. The one time you don't may have been the wrong one to trust. The ambulance IS very bumpy and ET tubes DO migrate.

Good call on the re-verify. Think about it: a tube is placed on scene. The patient is then moved to the rig (maybe up/down some stairs), then into the rig, then on a bumpy ride, then moved out of the rig, then into the ER (maybe some uneven terrain again), and lastly transferred from the stretcher to the ER bed. Man, that is a whole lotta opportunity for a dislodged tube. I have seen this several times in the ER, and the response is always the same: But I visualized the chords!

 

[rhan101277]

Don't "count" on your tube. Verify and RE-verify your placement. The one time you don't may have been the wrong one to trust. The ambulance IS very bumpy and ET tubes DO migrate.

Yeah this is good advice. With waveform capnography monitoring, viewing chest rise and fall, hopefully when it comes my turn I can do good. Obviously after the tube is passed and I check breath sounds, I won't be able to check them again when i am by myself in the back. I will have to depend on my equipment and viewing chest rise/fall, condensation on the tube etc.

I would be hosed up if someone got brain damage or something because a tube became dis-lodged and I missed it. I just need to do my best.

 

[boingo]

I take intubated patients into the ED with the monitor. I print out a copy of the waveform at the bedside, and hand it off and verbalize it as well. If things change after that, the ED would be hard pressed to fault the medic, IMHO.

 

[VentMedic]

I take intubated patients into the ED with the monitor. I print out a copy of the waveform at the bedside, and hand it off and verbalize it as well. If things change after that, the ED would be hard pressed to fault the medic, IMHO.

However, what I have found is some Paramedics run their ETTs very high and even though the tip is through the cords, the cuff is above or supraglottic. The seal will be just enough where you will still get a waveform but essentially the tube is in a very unstable position. Careful documentation of placement at the cm mark must be made and what your reference point is. Hospitals will generally refer to the teeth, lip or gum line. Paramedics may refer to where they have attached it at the commercial tube holder device. The Thomas tube holder is definitely one to be careful with. The 23 cm mark at the screw may be anywhere from 19 - 21 cm at the lip and on a 5'10" pt or taller, that tube may be very close to out or the cuff may not be below the cords. It wouldn't take much more than a move from the stretcher to stretcher with the BVM still attached or head positioning to dislodge to tube to a bad position. Also, it doesn't take much of a cough for a patient to move this device as well since the straps stretch.

http://www.armstrongmedical.com/index.cfm/go/product.detail/sec/3/ssec/16/cat/71/fam/509

 

[boingo]

Good points. In addition to printing off the waveform at the bedside I will report the tube depth as well, I usually reference the teeth, if not, I will specify, gums, lips, etc...I document the grade of view, number of attempts and any difficulty encountered. I will note the airway score pre-intubation if it was performed.

 

[VentMedic]

Those who do NTI also fall very short on some patients. A 6.0 or 6.5 tube will only be about 28 and 29 cm which might be a great depth for some orally intubated patients but even then we might be taping at the hub if that tube is used. For NTI, the cuff will more than likely be supraglottic.

It would be great if everyone was taught to score the airway for degree of difficulty before just taking a few stabs at it.

 

[MedicMeJJB]

The point here was nailed several times.. LMAs are made for NPO patients, prior to surgeries. They are ideal for that situation, ET intubation is ideal for truly securing an airway - SO LONG AS IT IS DONE CORRECTLY! Confirmed.. Reconfirmed.. and then recomfirmed again!

 

[VentMedic]

That does not mean you shouldn't be proficient in at least one and preferrably two alternative airways which might include the LMA. If for some reason I could not do ETI on someone who has esophageal varices, I would be very reluctant to an alternative airway that went into the esophagus if I had to establish some type of airway to get from point A to point B.

 

[MedicMeJJB]

Absolutely agreed. I didn't mean that ET is the only way, sorry if it came across that way. All advanced providers should be proficient and trained in several alternatives. We are currently carry the King tube and Combi tubes, also. Surgical airways cannot be forgotten. ALL starting with good, proficient BLS bagging. B)

 

[phildo]

Something I do to mitigate tube displacement is to apply a cervical collar, and immobilize the patient on a long spineboard with headblocks prior to moving them. Really helps if you have to carry them downstairs, like I had to do last shift with a really large OD patient that I had to RSII. I make sure to tell the ER staff that it was only to facilitate movement.