Extraglottic Devices Research Articles

Extraglottic device use is rare during emergency airway management: A National Emergency Airway Registry (NEAR) study

IntroductionAirway management is a critical component of the management of emergency department (ED) patients. The ED airway literature primarily focuses upon endotracheal intubation; relatively less is known about the ED use of extraglottic devices (EGDs). The goal of this study was to describe the frequency of use, success, and complications for EGDs among ED patients. MethodsThe National Emergency Airway Registry (NEAR) is a prospective, multi-center, observational registry. It captures data on all ED patients at participating sites requiring airway management. Intubating clinicians entered all data into an online system as soon as practical after each encounter. We conducted a secondary analysis of these data for all ED encounters in which EGD placement occurred. We used descriptive statistics to characterize these encounters. ResultsOf 19,071 patients undergoing intubation attempts, 56 (0.3%) underwent EGD placement. Of 25 participating sites, 13 reported no cases undergoing EGD placement; the median number of EGDs placed per site was 2 (interquartile range 1–2.5, range 1–31). Twenty-nine (54%) patients had either hypotension or hypoxia prior to the start of airway management. Clinicians reported anticipation of a difficult airway in 55% and at least one difficult airway characteristic in 93% of these patients. Forty-one encounters entailed placement of a laryngeal mask airway (LMA®) Fastrach™, 33 of whom underwent subsequent successful intubation through the EGD and 7 of whom underwent intubation by alternative methods. An additional 10 encounters utilized a standard LMA® device. Providers placed 34 (61%) EGDs during the first intubation attempt. Seventeen EGD patients (30%) experienced peri-procedure adverse events, including 14 (25%) experiencing hypoxemia. None of these patients expired due to failed airways. ConclusionsEGD use was rare in this multi-center ED registry. EGD occurred predominantly in patients with difficult airway characteristics with favorable airway management outcomes. Clinicians should consider this emergency airway device for patients with a suspected difficult airway.

THE HENNEPIN DOUBLE-TUBE TECHNIQUE: A MORE EFFICIENT METHOD OF TRACHEAL INTUBATION THROUGH THE LMA FASTRACH

BackgroundThe LMA Fastrach (LMA North America, Inc; hereafter termed the intubating laryngeal mask airway [ILMA]) is an extraglottic device designed to facilitate endotracheal intubation. After the endotracheal tube is placed through the lumen of the ILMA into the trachea, the ILMA is removed, using a proprietary stabilizer rod to hold the tube in place. DiscussionThe traditional method of ILMA removal is not optimized for the critically ill patient. It requires the use of unfamiliar equipment, exposes the patient to a significant period without ventilation, and risks tube dislodgement. We designed a simple technique with a double-endotracheal tube setup that addresses these problems using common equipment, allowing for continuous ventilation, and minimizing the risk of tube dislodgement. ConclusionsThe traditional method of ILMA removal around an endotracheal tube is not designed for critically ill patients or the physicians taking care of them. This novel technique is designed to improve the usability of the ILMA for physicians and improve airway outcomes for patients.

Rapid Sequence Airway with the Intubating Laryngeal Mask in the Emergency Department.

The administration of sedation and neuromuscular blockade to facilitate extraglottic device (EGD) placement is known as rapid sequence airway (RSA). In the emergency department (ED), EGDs are used largely as rescue devices. In select patients, there may be significant advantages to using EGDs over laryngoscopy as the primary airway device in the ED. Our study sought to describe the practice of RSA in the ED, including rates of successful oxygenation, ventilation, and complications from EGD use. We identified patients in the ED between 2007 and 2017 who underwent RSA with the LMA® Fastrach™ (hereafter termed ILMA; Teleflex Medical Europe Ltd., Athlone, Ireland) placed as the first definitive airway management device. A trained abstractor performed chart and video review of the cases to determine patient characteristics, physician use of the ILMA, indication for ILMA placement, success of oxygenation and ventilation, success of intubation, and complications related to the device. During the study period, 94 patients underwent RSA with the ILMA. Of those, 93 (99%) were successfully oxygenated and ventilated, and when intubation was attempted, 89% were able to be intubated through the ILMA. The incidence of vomiting and aspiration was 1% and 3%, respectively. There were 30 different attending physicians who supervised RSA and the median number was 2 per physician in the 10-year study period. The practice of RSA with the ILMA in the ED is associated with a high rate of successful oxygenation, ventilation, and intubation with infrequent complications, even when performed by physicians with few experiences in the approach.

Brief Research Report: Prehospital Rapid Sequence Airway

Background Rapid Sequence Airway (RSA) describes the administration of an induction agent and paralytic followed by the intended primary placement of an extraglottic airway device rather than an endotracheal tube. The purpose of this study was to determine the success rates for prehospital RSA. The secondary goal was to determine aspiration rates among patients managed with RSA. Methods Adult and pediatric prehospital RSA cases between 2005 and 2017 reported to an airway quality assurance registry from one ground and one air agency were reviewed. Success was defined as the ability to adequately ventilate patients after extraglottic device placement. Aspiration was defined as radiologic evidence (chest x-ray or CT scan) within 48 hours of hospital presentation. Results 68 patients underwent RSA with a King LTS-D (n = 24), LMA-Supreme (n = 28), Combitube (n = 2), LMA-Unique (n = 8) and iGel (n = 6). Age ranged from 1 year to 73 years with 10 patients less than 18. RSA was successful in 64 (94%) cases; 56 (88%) were successful on first pass and 63 (98%) within 2 attempts. The RSA procedure occurred in an aircraft in 14 (21%) of cases and 71% of patients were in cervical precautions. Duration of EGD insertion prior to hospital arrival ranged from 5 to 102 minutes with an average of 34.5 minutes. Aspiration data was available for 46 patients of whom 4 (8.7%) were found to have evidence of aspiration. Conclusion Overall and first pass RSA success rates were high and aspiration rates were low in this quality assurance registry despite predictors of airway difficulty. RSA may be a reasonable alternative to RSI for prehospital airway management that merits further research.

The Importance of the Intubation Process for the Safety of Emergency Airway Management.

The Importance of the Intubation Process for the Safety of Emergency Airway Management.

Does the revised intubating laryngeal tube (ILTS-D2) perform better than the intubating laryngeal mask (Fastrach)? \u2013 a randomised simulation research study

BackgroundThe intubating laryngeal tube (ILTS-D™) and the intubating laryngeal mask (Fastrach™) are devices that facilitate both extraglottic application and blind tracheal intubation. A revised model of the iLTS-D (for scientific reasons called ILTS-D2) has been designed but not yet evaluated. Therefore, we compared the ILTS-D2 with the established Fastrach under controlled conditions in a prospective randomised controlled simulation research study.MethodsAfter ethical approval, we randomised 126 medical students into two groups. Each participant received either Fastrach or ILTS-D2 to perform five consecutive ventilation attempts in a manikin. The primary endpoint was the time to ventilation in the last attempt of using the devices as extraglottic devices. Secondary endpoints were the time to tracheal intubation and the success rates.ResultsThere was no relevant difference between the two devices in the time to ventilation in the last of five attempts (Fastrach: median 14 s [IQR: 12–15]; ILTS-D2: median 13 s [IQR: 12–15], p = 0.592). Secondary endpoints showed a 2 s faster blind tracheal intubation using the Fastrach than using the ILTS-D2 (Fastrach: median 14 s [IQR: 13–17]; ILTS-D2: median 16 s [IQR: 15–20] p < 0.001). For both devices, the success rates were 100% in the last attempt.ConclusionsConcerning extraglottic airway management, we could not detect a relevant difference between the revised ILTS-D2 and the Fastrach under laboratory conditions. We advocate for an evaluation of the ILTS-D2 in randomised controlled clinical trials.Trial registrationIdentifier at clinicaltrials.gov: NCT03542747. May 31, 2018

Efficacy of Laryngeal Tube versus Bag Mask Ventilation by Inexperienced Providers.

IntroductionBag mask ventilation (BMV) and extraglottic devices (EGDs) are two common methods of providing rescue ventilation. BMV can be difficult to perform effectively, especially for inexperienced providers and in patients with difficult airway characteristics. There is some evidence that the laryngeal tube (LT) can be successfully placed by inexperienced providers to provide effective ventilation. However, it is unclear whether ventilation provided by LT is superior to that of BMV, especially in the hands of inexperienced airway providers. Therefore, we aimed to compare ventilation efficacy of inexperienced airway providers with BMV versus LT by primarily measuring tidal volumes and secondarily measuring peak pressures on a simulated model.MethodsWe performed a crossover study first year emergency medicine residents and third and fourth year medical students. After a brief instructional video followed by hands on practice, participants performed both techniques in random order on a simulated model for two minutes each. Returned tidal volumes and peak pressures were measured.ResultsTwenty participants were enrolled and 1200 breaths were measured, 600 per technique. The median ventilation volumes were 194 milliliters (mL) for BMV, and 387 mL for the laryngeal tube, with a median absolute difference of 170 mL (95% confidence interval [CI] 157–182 mL) (mean difference 148 mL [95% CI, 138–158 mL], p<0.001). The median ventilation peak pressures were 23 centimeters of water (cm H2O) for BMV, and 30 cm H2O for the laryngeal tube, with a median absolute difference of 7 cm H2O (95% CI, 6–8 cm H2O) (mean difference 8 cm H2O [95% CI, 7–9 cm H2O], p<0.001).ConclusionInexperienced airway providers were able to provide higher ventilation volumes and peak pressures with the LT when compared to BMV in a manikin model. Inexperienced providers should consider using an LT when providing rescue ventilations in obtunded or hypoventilating patients without intact airway reflexes. Further study is required to understand whether these findings are generalizable to live patients.

Impact of an Extraglottic Device on Pediatric Airway Management in an Urban Prehospital System.

IntroductionPrehospital pediatric endotracheal intubation has lower first-pass success rates compared to adult intubations and in general may not offer a survival benefit. Increasingly, emergency medical services (EMS) systems are deploying prehospital extraglottic airways (EGA) for primary pediatric airway management, yet little is known about their efficacy. We evaluated the impact of a pediatric prehospital airway management protocol change, inclusive of EGAs, on airway management and patient outcomes in children in cardiac arrest or respiratory failure.MethodsUsing data from a large, metropolitan, fire-based EMS service, we performed an observational study of pediatric patients with respiratory failure or cardiac arrest who were transported by EMS before and after implementation of an evidence-based airway management protocol inclusive of the addition of the EGA. The primary outcome was change in frequency of intubation attempts when paired with an initial EGA. Secondary outcomes included EGA and intubation success rates and patient survival to hospitalization and discharge.ResultsWe included 265 patients age <16 years old, with 142 pre- and 123 post-protocol change. Patient demographics and event characteristics were similar between groups. Intubation attempts declined from 79.6% pre- to 44.7% (p<0.01) post-protocol change. In patients with an intubation attempt, overall intubation success declined from 81.4% to 63.6% (p<0.01). Post-protocol change, an EGA was attempted in 52.8% of patients with 95.4% success.ConclusionImplementation of an evidenced-based airway management algorithm for pediatric patients, inclusive of an EGA device for all age groups, was associated with fewer prehospital intubations. Intubation success may be negatively impacted due to decreases in procedural frequency.

July/August 2018 Forum

There has been a shift from endotracheal intubation (ETI) toward extraglottic devices (EGDs) for prehospital airway management. A concern exists that this may lead to more frequent cases of aspiration.This was a retrospective study using a prehospital quality assurance database. Patients were assigned to groups based on the method that ultimately managed their airways (EGD or ETI). Cases with documented blood/emesis obscuring the airway were considered inevitable aspiration cases and excluded. Aspiration was defined by the radiology report within 48 hours.A total of 104 EGD and 152 ETI patients were identified. Aspiration data were available for 67 EGD and 94 ETI cases. Of those, 8 EGD and 3 ETI cases had blood/emesis obscuring the airway and were excluded as planned. After exclusions, there were 5 EGD and 11 ETI cases in which aspiration was later diagnosed (EGD aspiration rate = 8%, ETI aspiration rate = 12%; χ2: P = .359; relative risk = .841; 95% confidence interval, .329-2.152).In this small quality assurance database, aspiration rates were not significantly different for prehospital patients managed with an EGD versus ETI.

Preliminary Report: Comparing Aspiration Rates between Prehospital Patients Managed with Extraglottic Airway Devices and Endotracheal Intubation

IntroductionThere has been a shift from endotracheal intubation (ETI) toward extraglottic devices (EGDs) for prehospital airway management. A concern exists that this may lead to more frequent cases of aspiration. MethodsThis was a retrospective study using a prehospital quality assurance database. Patients were assigned to groups based on the method that ultimately managed their airways (EGD or ETI). Cases with documented blood/emesis obscuring the airway were considered inevitable aspiration cases and excluded. Aspiration was defined by the radiology report within 48 hours. ResultsA total of 104 EGD and 152 ETI patients were identified. Aspiration data were available for 67 EGD and 94 ETI cases. Of those, 8 EGD and 3 ETI cases had blood/emesis obscuring the airway and were excluded as planned. After exclusions, there were 5 EGD and 11 ETI cases in which aspiration was later diagnosed (EGD aspiration rate = 8%, ETI aspiration rate = 12%; χ2: P = .359; relative risk = .841; 95% confidence interval, .329-2.152). ConclusionIn this small quality assurance database, aspiration rates were not significantly different for prehospital patients managed with an EGD versus ETI.

Extraglottic airway devices: technology update.

Extraglottic airway devices (EADs) have revolutionized the field of airway management. The invention of the laryngeal mask airway was a game changer, and since then, there have been several innovations to improve the EADs in design, functionality, safety and construction material. These have ranged from changes in the shape of the mask, number of cuffs and material used, like rubber, polyvinylchloride and latex. Phthalates, which were added to the construction material in order to increase device flexibility, were later omitted when this chemical was found to have serious adverse reproductive outcomes. The various designs brought out by numerous companies manufacturing EADs resulted in the addition of several devices to the airway market. These airway devices were put to use, many of them with inadequate or no evidence base regarding their efficacy and safety. To reduce the possibility of compromising the safety of the patient, the Difficult Airway Society (DAS) formed the Airway Device Evaluation Project Team (ADEPT) to strengthen the evidence base for airway equipment and vet the new extraglottic devices. A preuse careful analysis of the design and structure may help in better understanding of the functionality of a particular device. In the meantime, the search for the ideal EAD continues.

Airway management in intensive care units in Rhineland-Palatinate : Evolution over five years

Securing the airway in severely ill patients is associated with ahigh rate of complications. So far, no information exists about the equipment readily available for airway management in German intensive care units (ICUs). It is also unknown if the range of material has improved over time. In the present trial the availability of equipment for airway management in ICUs in Rhineland-Palatinate was evaluated at two different times. Using astructured questionnaire, all ICUs in the state were contacted in the years 2010 and 2015. The availability of different types of equipment for airway management, as well as the presence of atraining program for airway management, was evaluated. For 2010 data from 64ICUs were evaluated and for 2015 data sets from 63ICUs were collected. In 2010 indirect laryngoscopes were available in eight ICUs; in 2015 these devices were directly accessible in 43units (p< 0.0001). Extraglottic devices were available in all but one ICU in 2010 and all ICUs in 2015. Equipment for emergency surgical airway procedures was available in nearly every ICU (n= 60). The availability of capnography increased significantly from 2010 (n= 12) to 2015 (n= 56; p< 0.0001). In 2010 and 2015, frequent training with afocus on airway management was performed in 23 and 32units, respectively (p> 0.05). Most ICUs in Rhineland-Palatinate have abroad range of equipment for airway management available, and the range has significantly improved over the time period evaluated. The availability of indirect laryngoscopes and capnometers improved significantly. However, it is remarkable that in some ICU's there is still alack of equipment for advanced airway management.

In Response

Incomplete Airway Assessment We thank Dr. Nørskov et al1 for their thoughtful comments concerning our editorial.2 We also are grateful for their clarification of methods used for airway assessment in their Danish Anaesthesia Database study.1 Although it is clear that airway evaluation before intervention is a critical step to minimize adverse outcomes, we agree with Nørskov et al1 that there is ample room for improvement in the evaluation tools we have to date. In other words, because unanticipated difficulties in managing the airway will likely continue to occur in our clinical practice, airway practitioners must be equipped with a strategy to manage an unanticipated difficult or failed airway (ie, plan B, plan C).3–5 Recognizing that the survey mentioned in our editorial2 was an informal solicitation of information regarding the airway evaluation section of preanesthetic assessment forms (an image taken from a smartphone), there is potential for bias in our data collection. The countries involved in our survey included Australia, Canada, England, Germany, Italy, the Netherlands, New Zealand, Singapore, Rwanda, and the United States. As summarized in our editorial, the airway assessment section on these forms varied substantially, ranging from descriptive text only to a list of predictors of difficult direct laryngoscopy with Mallampati score, this latter, the most common predictor present on these preanesthetic assessment forms. On the basis of the information collected, we concluded that assessment for difficult direct laryngoscopy remains the main focus of airway assessment at many centers around the globe. The form from our center at Dalhousie University was the only one asking for predicted difficulty in bag-mask ventilation and surgical airway (cricothyrotomy). None of the forms surveyed queried assessment of predicted difficulty in using an extraglottic device, such as a laryngeal mask airway. We agree with Nørskov et al1 that we must find solutions to improve and correct problems related to incomplete airway assessment. In addition to assessing the patient for predicted difficulty with direct or video laryngoscopy, we must stress the importance of assessing difficulties in other methods in oxygenation and ventilation. These include difficulties in bag-mask ventilation, the use of an extraglottic device (eg, a laryngeal mask airway), and front-of-neck access (cricothyrotomy) so that appropriate airway management strategies can be planned before intervention. Adverse patient physiology (eg, full stomach, anticipated intolerance of apnea) with the potential to impact the choice of approach to the airway also must be considered. Orlando Hung, MD, FRCPCJ. Adam Law, MD, FRCPCIan Morris, MD, FRCPCDepartment of Anesthesia, Pain Management andPerioperativeMedicineDalhousie UniversityHalifax, Nova Scotia, Canada[email protected] Michael Murphy, MD, FRCPCDepartment of Anesthesiology and Pain MedicineUniversity of AlbertaEdmonton, Alberta, Canada

Tracheal Malplacement of the King LT Airway May Be an Important Cause of Prehospital Device Failure

BackgroundThe King LT airway (King Systems, Noblesville, IN) is a popular extraglottic device that is widely used in the prehospital setting. We report a case of tracheal malplacement of the King airway with a severe kink in the distal tube. Case ReportA 51-year-old unhelmeted motorcyclist collided with a freeway median and was obtunded when paramedics arrived. After bag mask ventilation, a King airway was placed uneventfully and the patient was transported to the emergency department. Because of the concern for an unstable cervical spine injury, a lateral cervical spine radiograph was obtained on arrival. No cervical injury was seen, but the King airway was noted to be malplaced; the King airway passed through the laryngeal inlet and became lodged on the anterior trachea, creating an acute kink between the two balloons. After reviewing the radiograph, ventilations were reassessed and remained adequate. Both balloons were deflated, and the King airway was removed; the patient was orotracheally intubated without complication. Why Should An Emergency Physician Be Aware of This?The King airway is a valuable prehospital airway that can be placed quickly and blindly with high success rates by inexperienced providers; the King airway, however, is not without complication. Ventilation was not impaired in this patient, but tracheal malplacement may be an important cause of prehospital device failure. If a first placement attempt of a King airway device fails, it is reasonable to reattempt King airway placement with a new, unkinked device before abandoning King airway placement.

Abstract PR585

Background & Objectives: Anesthesiologists from high-income countries are increasingly interested in global humanitarian missions in LMLRCs, and airway management skills are required in adequate emergencies management. There is growing evidence of the successfully use of Airtraq to assist both expected and unexpected difficult intubation scenarios, and we hypothesize if it would be an optimal device in LMICs. Materials & Methods: Between 2014 and 2016 we accomplish 600 preanesthesia evaluations, and carried out a retrospective review of difficult intubations situations occurred in the 200 procedures performed at the Auberge de l’Amour Redempteur hospital, Dangbo, Benin. Individual data points included age, sex, surgical indication and procedure, airway device employed, and outcomes. Results: In adults, the most common surgical indication were both giant inguinal hernia and giant goiter. We found Airway-related symptoms in 85% goiter patients (13), with predictive factors of difficult intubation in 100% (16). Airway management of thyroid surgeries were performed with Airtraq and Frova extraglottic device without complications.Conclusion: More than 230 million surgical procedures are annually performed in the world, 8.1 million (3.5%) in LMLRCs. Difficult airway management is especially important in these contest. DAS 2015 guidelines remember human factors issues contributed to adverse outcomes in 40% of the instances reported to the NAP4, and explicitly indicate that in Unanticipated Difficult Intubations cases reported Airtraq was used most frequently. Endotracheal intubation is a lifesaving procedure, but a difficult skill to learn and requires a great deal of clinical experience to master. Videolaryngoscopes offer an improved view compared with conventional laryngoscopy,and all anaesthetists should be trained to use, and have immediate access to a videolaryngoscope. Airtraq have proved advantages over the direct laryngoscope, portable, resistant, economical and cost-effective. And this review of 16 goiter LMICs procedures provides valuable insight into the opinnion that Airtraq should be a gold standar in airway management LMLRCs. Disclosure of Interest: None declared

Device and Medication Preferences of Canadian Physicians for Emergent Endotracheal Intubation in Critically Ill Patients.

Various medications and devices are available for facilitation of emergent endotracheal intubations (EETIs). The objective of this study was to survey which medications and devices are being utilized for intubation by Canadian physicians. A clinical scenario-based survey was developed to determine which medications physicians would administer to facilitate EETI, their first choice of intubation device, and backup strategy should their first choice fail. The survey was distributed to Canadian emergency medicine (EM) and intensive care unit (ICU) physicians using web-based and postal methods. Physicians were asked questions based on three scenarios (trauma; pneumonia; heart failure) and responded using a 5-point scale ranging from "always" to "never" to capture usual practice. The survey response rate was 50.2% (882/1,758). Most physicians indicated a Macintosh blade with direct laryngoscopy would "always/often" be their first choice of intubation device in the three scenarios (mean 85% [79%-89%]) followed by video laryngoscopy (mean 37% [30%-49%]). The most common backup device chosen was an extraglottic device (mean 59% [56%-60%]). The medications most physicians would "always/often" administer were fentanyl (mean 45% [42%-51%]) and etomidate (mean 38% [25%-50%]). EM physicians were more likely than ICU physicians to paralyze patients for EETI (adjusted odds ratio 3.40; 95% CI 2.90-4.00). Most EM and ICU physicians utilize direct laryngoscopy with a Macintosh blade as a primary device for EETI and an extraglottic device as a backup strategy. This survey highlights variation in Canadian practice patterns for some aspects of intubation in critically ill patients.

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Prehospital airway technique does not influence incidence of ventilator-associated pneumonia in trauma patients.

The relationship between the prehospital airway device used and later development of ventilator-associated pneumonia (VAP) is unknown. We sought to determine if the prehospital airway device choice is associated with an increased risk of VAP in risk-adjusted critically injured patients. We performed a retrospective analysis of all trauma patients requiring definitive airway placement before intensive care unit admission at a Level I trauma center from 2008 to 2012. Prehospital airway management strategies were classified as extraglottic device placement, endotracheal intubation, bag-valve mask ventilation (BVM), or lack of a prehospital airway with subsequent intubation at the trauma center. Patients were excluded if they were hospital transfers, were dead on arrival, died in the emergency department, or did not require at least 48 hours of mechanical ventilation. The primary end point was the development of VAP as determined by institutional guidelines for diagnosis. Logistic regression was used to determine risk factors for VAP. A total of 317 patients met inclusion criteria. The median age was 37 years (interquartile range, 25-51 years), 75% were male, 78% sustained a blunt injury, and the median Injury Severity Score (ISS) was 29 (interquartile range, 21-34). Ninety-seven patients (30.6%) developed VAP. Prehospital airway strategies were as follows: 17 (5.4%) had extraglottic device placement, 28 (8.8%) had BVM, 84 (26.5%) had endotracheal intubation, and 188 (59.3%) had no prehospital airway placement and were intubated after arrival. The type of prehospital airway was not statistically significant in terms of VAP development (range, 26.1-42.9%; p = 0.15). The only statistically significant predictor of VAP was length of mechanical ventilation (univariate: odds ratio, 1.14; 95% confidence interval, 1.10-1.18; p ≤ 0.01; multivariate: odds ratio, 1.15; 95% confidence interval, 1.10-1.20; p ≤ 0.01). Our data suggest that the prehospital airway device used was not associated with the development of VAP. Therapeutic study, level IV; epidemiologic study, level III.

Retrograde Intubation with an Extraglottic Device in Place

BackgroundThe intubating laryngeal mask airway (ILMA) is an extraglottic device with a high rate of successful ventilation and oxygenation. Most modern airway algorithms suggest using an extraglottic device as the first-line rescue technique for a failed airway in emergency airway management. Eventually, a more secure airway is needed if the extraglottic temporizing device is working well. Retrograde intubation is a surgical airway management technique that is effective but relatively slow, making it most useful when ventilation can be maintained during the procedure. Case ReportWe report 2 cases of difficult emergency airway management with an ILMA used initially and retrograde intubation later used to establish a more secure airway. Why Should an Emergency Physician Be Aware of This?Retrograde incubation can be performed with an LMA in place for complicated airway management.

The i-gel vs. the PRO-Breathe Laryngeal Mask Airway in Children

The i-gel is an extraglottic device with a noninflatable cuff made of a flexible gelatinous material. The PRO-Breathe is a silicone-based standard laryngeal mask airway (LMA) device. The i-gel has been shown to be effective and easy to place in adults and children, but questions remain regarding the degree of leakage and the effectiveness …