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Thu Aug 25 01:42:21 BST 2005

34 is the numerator, not the denominator.

In fact the full reference is only an abstract, in the form of a conference abstract, published in that issue of AEM. The fact that the denominator is not given makes me intrinsically suspicious that it is not something they want to talk about, otherwise they would have told us. Is anyone aware of this study having ever been written up as a peer reviewed paper?

I'm not criticising the device (the ILMA is the device of choice for failed emergency intubation and I've said so myself in a review I recently wrote on difficult airway management in trauma). I use it myself when necessary and it has got me (and the patient) out of nasty situations a couple of times.

I'm just making the comment that we shouldn't draw too many conclusions from a non peer reviewed conference abstract where it is likely the baseline airway management isn't too good.

Cheers, Ian

Ian Seppelt FANZCA FJFICM
Staff Specialist in Intensive Care Medicine
The Nepean Hospital, 
PO Box 63, Penrith NSW 2751
Clinical Lecturer, University of Sydney

>>> "Mike MacKinnon" <mmackinnon at cox.net> 08/25/05 02:16am >>>
Here is the journal reference

However, it appears to me the denominator is right in the abstract 
Thirty-four patients were enrolled from 11/99 to 10/02. The idea of getting
a large number of people would be difficult as most intubations are not
failed. I have had my hands on this thing myself and was amazed with how
easy to use it was. Great tool and definitely the gold standard backup
airway.  

Academic Emergency Medicine Volume 10, Number 5 467, 
© 2003 Society for Academic Emergency Medicine 

AIRWAY MANAGEMENT

Use of the Intubating Laryngeal Mask Airway in Prehospital Patients with
Failed Rapid Sequence Intubation 
Michael Gibbs, Eric Swanson, Vivek Tayal, Bruce Horwood, Deepi Goyal, Steve
Carlton and Mark Lowell 
Maine Medical Center: Portland, ME, University of Utah: Salt Lake City, UT,
Carolinas Medical Center: Charlotte, NC, Maricopa Medical Center: Phoenix,
AZ, Mayo Clinic: Rochester, MN, University of Cincinnati: Cincinnati, OH,
University of Michigan: Ann Arbor, MI

Mike MacKinnon CEN CFRN BSN RN
"I reject your reality and substitute it with my own!"
mmackinnon at cox.net 
-------Original Message-------

From: Ian Seppelt
Date: 08/24/05 00:24:17
To: mmackinnon at cox.net; trauma-list at trauma.org 
Subject: RE: OPA Vs LMA

Can we have the full reference, please ie journal and citation details.

Just going on the abstract: 34 failed intubations in three years is a pretty
high number. What is the denominator? There are series in the literature
with up to 10% failed intubation rates and that makes me shudder when we
know that the incidence of difficult intubation in high risk obstetrics is
less than 1 : 200 and in general surgery is about 1: 4000. With a well
trained crew there is no reason you should have any more than about a 1%
difficulty rate and that can certainly be acheived prehospital. I used to
work for an aeromedical service that in 10 years did 7000 jobs, of whom
about 10% were intubated by the team rather than by prior personnel or not
needing intubation. At that stage they boasted 2 failed intubations and a
single surgical airway ie about a 1:350 failed intubation rate. I'm been
away for a few years but I'm not aware that things have deteriorated since
then.

So a valid reading of this paper would be: "inadequately skilled personnel
with a high baseline failed intubation rate had 82% success rate using the
ILMA."

If someone can send me the whole paper or whole citation (or just tell us
the denominator) I would be happy to be proven overly cynical. I will
publicly apologise if they did over 3000 intubations in that time period!

Cheers, Ian

Ian Seppelt FANZCA FJFICM
Staff Specialist in Intensive Care Medicine
The Nepean Hospital,
PO Box 63, Penrith NSW 2751
Clinical Lecturer, University of Sydney

>>> mmackinnon at cox.net 08/24/05 03:45am >>>
Hello.

That actually isnt true.

The study was done through maricopa county hospital in Phoenix Arizona. Dr
Bruce Horwood was apart of it as was the air medical company LifeNet

  AIRWAY MANAGEMENT

Use of the Intubating Laryngeal Mask Airway in Prehospital Patients with
Failed Rapid Sequence Intubation
Michael Gibbs, Eric Swanson, Vivek Tayal, Bruce Horwood, Deepi Goyal, Steve
Carlton and Mark Lowell
Maine Medical Center: Portland, ME, University of Utah: Salt Lake City, UT,
Carolinas Medical Center: Charlotte, NC, Maricopa Medical Center: Phoenix,
AZ, Mayo Clinic: Rochester, MN, University of Cincinnati: Cincinnati, OH,
University of Michigan: Ann Arbor, MI
ABSTRACT
Objectives: As neuromuscular blockade becomes more widely used in the
prehospital setting rational approaches to airway rescue must be adopted.
The purpose of this study was to evaluate the use of the Intubating
Laryngeal Mask Airway (ILMA) in patients with failed
rapid-sequence-intubation (RSI). Methods: We conducted a prospective,
observational study at six tertiary-care, hospital-based, air medical
transport programs where RSI is utilized. Air medical personnel completed
standardized LMA manikin-based training. The study protocol utilized the
ILMA as a rescue device in consecutive "failed RSI" cases (>3 intubation
attempts and/or inability to ventilate). Demographic information, reasons
for failed RSI, success of ILMA insertion, and complications were recorded
on a standardized data form. Results: Thirty-four patients were enrolled
from 11/99 to 10/02. No patients meeting the failed RSI definition were
excluded during the study period. The mean subject age was 36 years (range
14*79), 50% were male. Ninety-four percent of patients were injured. Reasons
for failed RSI included inadequate visualization (76%), bleeding/secretions
(68%), altered airway anatomy (44%) and esophageal intubation (38%).
Successful LMA ventilation was achieved in 100% of patients (94% 1st attempt
  6% 2nd attempt). Insertion of the ILMA endotracheal component was
successful in 28 (82%) patients (70% 1st attempt, 12% 2nd attempt). Rescue
cricothyrotomy was required in 2 patients. Complications were observed
during airway management in 40% of patients although none appeared
attributable to ILMA use. Conclusions: Following standardized training, air
medical providers were able to effectively utilize the ILMA as a rescue
device. Successful LMA ventilation was achieved in all failed RSI patients
while successful passage of the ILMA endotracheal component proved more
difficult with an 82% rate of success.

Mike MacKinnon CEN CFRN BSN RN
"I reject your reality and substitute it with my own!"
mmackinnon at cox.net 
-------Original Message-------

From: Keneth Henriette
Date: 08/23/05 04:31:32
To: Trauma & Critical Care mailing list
Subject: RE: OPA Vs LMA

What about the Fastrach (intubating LMA)? It has been used in emergency
situations, for example facial traumas and cervical spine fractures.
There's no study to clarify its place in pre-hospital seeting or the ER.

Kenneth
-----Original Message-----
From: Neil Thomson [mailto:dr.n.thomson at btopenworld.com] 
Sent: Tuesday 23 August,2005 1:46 AM
To: trauma-list at trauma.org 
Subject: OPA Vs LMA

Hi Roger,

Gold Standards are either Cuffed oral ETT in the correct place (with the
cuff inflated and attached to an appropriate source of ventilation and
oxygen) or a spontaneously breathing patient (in a lateral position if
they
have an altered GCS and / or any potential for airway compromise)

The Guedel O-P tube * has its place in helping to open and maintain the
patient's airway, but it's major failing (and I've seen some horrors) is
that it DOES NOT PROTECT THE PATIENT FROM ASPIRATION!!!!

The best use for an OP tube is as a bite-block to stop the patient from
chewing down on the ET Tube - in general, if the patient will tolerate
and
OP Tube, they should probably be intubated.

* I don't let my students call it an 'airway' - to remind them that only
the
patient has an airway, and that this is only a plastic tube that may or
may
not be helpful, and could be dangerous if the assumption that once it is
in
place the airway is safe.

The LMA was never designed as an emergency / pre-hospital device, but
seems
to be becoming more popular. I have found it invaluable for trapped
patients
who needed an ET tube, but their position relative to their surroundings
prevented this). It can be inserted 'blindly' and offers reasonable
protection against passive airway soiling. (If the patient starts
actively
vomiting, it should be removed)

Some services are talking about introducing LMA's at a relatively junior
level, as a reasonable airway in the arrested patient - especially with
single responders, as it allows one-handed bagging (which could be done
by a
by-stander or minimally trained first-aider)

Contact me off-list if you need any more info

Dr Neil Thomson

e        dr.n.thomson at btopenworld.com 
m       07919 961460
h        01908 521826

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