How to Use Supraglottic Airway Devices: A Comprehensive Guide

In emergency medicine, keeping the airway open is crucial. Sometimes, the usual ways to do this aren't quick or reliable enough. That's when Supraglottic Airway Devices step in. They're a useful option in Basic Life Support situations. Let's look at what they are, how to put them in, when to use them, and what's important to know for good BLS training.

Understanding Supraglottic Airway Devices

Supraglottic Airway Devices are tools used to manage the airway without putting a tube into the windpipe. They sit above the glottis, the opening into the windpipe, and help with breathing. These medical devices come in different types like:

• Laryngeal mask airways (LMAs)
• Laryngeal tube airways (LTAs)
• Esophageal-tracheal twin-lumen airways (Combitubes).

Supraglottic Airway Devices have been around since the early 20th century and were first used in anesthesia. Now, they're used in emergency medicine and Basic Life Support (BLS) because they're simple and work well to keep the airway open.

How to Use Supraglottic Airway Devices?

Here's a step by step guide on how to use supraglottic airway devices:

1. Patient Assessment: Before inserting any airway device, assessing the patient's condition and airway anatomy is essential. Ensure the patient is adequately sedated or unconscious.
2. Prepare Equipment: Gather the necessary equipment, including the chosen supraglottic airway device, lubricant, suction, and a securing device (like adhesive tape).
3. Positioning: The patient's head should be in a neutral position, with the neck slightly extended. This helps align the airway for easier insertion.
4. Pre-oxygenation: Administer pre-oxygenation to increase the oxygen reserve in the patient's lungs. This is done using a mask or other oxygen delivery systems.
5. Insertion: Hold the SAD device correctly according to its design (varies depending on the device). Usually, you insert it into the mouth and advance it along the palate, aiming for the posterior pharynx. Follow the manufacturer's guidelines for insertion depth and technique.
6. Confirmation: Confirm successfult placement of the SAD device by listening for bilateral breath sounds and observing chest rise. Use end-tidal CO2 monitoring to verify correct positioning.
7. Securing the Device: Once confirmed, secure the SAD device using adhesive tape or other devices to prevent accidental dislodgment.
8. Ventilation: Begin positive pressure ventilation using a bag-valve-mask device or a mechanical ventilator connected to the SAD device. Ensure adequate ventilation and monitor the patient's vital signs closely.
9. Monitoring: Throughout the procedure, continuously monitor the patient's vital signs, including oxygen saturation, end-tidal CO2, heart rate, and blood pressure.
10. Maintenance: Regularly assess and maintain the position of the SAD device throughout the procedure. Monitor for signs of displacement or air leakage.
11. Removal: Remove the SAD device gently once the procedure is complete, and the patient is awake and breathing spontaneously. Follow the manufacturer's instructions for removal to minimize discomfort and risk of injury.
12. Post-procedure Care: Provide appropriate post-procedure care, including monitoring the patient for any signs of airway obstruction, respiratory distress, or complications related to SAD use.

Patient Assessment

Before putting in the airway device, ensure the patient is asleep or not awake. Check if they are able to keep their airway open without help. Look at their airway to see if there might be any issues. Additionally, look at their airway's shape to anticipate any problems when putting in the device. This helps choose the right device and method for each patient.

Prepare Equipment for SAD Insertion

Getting the equipment ready is essential to ensure everything goes smoothly when managing the airway. Gather all the stuff you need, like the airway device you picked, some lube, a suction tool, and something to keep the device in place, like tape. Check that everything works well and is easy to reach. Choose the right size and type of airway device based on the patient's age, weight, and what's happening with them. Having everything ready to go before you start helps keep things on track and ensures the patient stays safe.

Positioning the Patient

Getting the patient in the right position is crucial for putting in and placing the airway device correctly. To position the patient correctly:

• Lay the patient flat on a surface like a table or stretcher, and make sure their head is in a straight position.
• Gently tilt their head back to help line up the airway better and make it easier to see during insertion.
• Make sure the patient feels comfy and is supported well to avoid any movements that could mess up the procedure.

Good positioning helps the airway device work better and lowers the chances of problems like the airway getting blocked or the device moving out of place.

Pre-oxygenation

Pre-oxygenation is important for managing the airway because it helps make sure the patient has enough oxygen and reduces the chance of them getting too little during the procedure. Give the patient lots of oxygen through a mask or tubes in their nose for a few minutes before you put in the airway device. Encourage them to take deep breaths and make sure the mask or tubes fit snugly over their nose and mouth to get the most oxygen in. Aim for their oxygen level to be at least 95% before you start. Pre-oxygenation lowers the risk of their oxygen level dropping too low while you're working on their airway and gives some extra safety in case there are any problems.

Insertion Techniques

Here's a proper SAD insertion technique:

• Hold the device the right way, following the instructions from the manufacturer on how to put it in.
• Gently push the device into the patient's mouth with steady pressure, aiming towards the back of their throat.
• Move it along the roof of the mouth until it's in the right spot, making sure it doesn't get blocked by the tongue or anything else in the way.
• Be careful not to push too hard to avoid hurting the patient's airway.

Doing it the right way and paying attention to details make it more likely that the device stays in place and the patient does well.

Confirmation of SAD Placement

Make sure the supraglottic airway device is in the right place to make sure the patient breathe well and to avoid problems. Use different ways to check if it's in the right spot, like listening, watching, and checking the patient's body. Listen to both sides of the chest with a stethoscope to make sure air is going in and out well. Watch the chest move up and down with each breath to see if it's working right.

Use a special machine called capnography to check the level of carbon dioxide in the breath. This shows if the device is in the windpipe or the food pipe. Keeping an eye on where the device is and how well it's working helps catch any problems quickly and fix them right away.

Securing the Supraglottic Device

After you're sure the supraglottic airway device is in the right place, you need to make sure it stays there. Use tape or something else to keep the device from moving by securing it in place. Make sure whatever you use isn't too tight, so it doesn't affect blood flow or make the patient uncomfortable. Keep checking the securing device during the procedure and adjust it if needed to make sure the device stays where it should. Making sure the device is secure helps keep it in place so the patient breathes well and lowers the chance of any problems from it moving.

Ventilation

Ventilation is a critical step after inserting the supraglottic airway device to ensure adequate oxygenation and ventilation of the patient. 

• Connect the device to a bag that you squeeze or a machine that helps with breathing, like a ventilator.
• Adjust how much air goes in and out as needed to make sure the patient gets enough oxygen and breathes at the right rate based on how they're doing.
• Keep a close eye on their vital signs like oxygen levels, heart rate, and blood pressure to make sure they're breathing okay and getting enough air.
• Check how well the ventilation is working regularly and change things if needed to keep the patient's oxygen and breathing good during the procedure.

Monitoring the Patient

Keeping a close eye on the patient during the airway management procedure is really important to catch any changes in their condition or how well the device is working. Use a monitor that checks different vital signs like oxygen levels, heart rate, blood pressure, and the level of carbon dioxide in their breath.

Watch out for signs that the airway might be blocked, they're not getting enough air, or the device isn't in the right place, like changes in breathing sounds, uneven chest movements, or high carbon dioxide levels. Stay alert and ready to fix any problems that come up, like moving the device, changing how they're getting air, or trying other airway treatments if needed. Checking on the patient regularly makes sure they stay safe and helps catch any issues early on to make things better.

Maintenance

Check the device often to make sure it's still in the right place, secured properly, and the airway stays clear. Keep an eye out for any signs that the device might have moved, air is leaking out, or something is blocking the airway, and fix them right away. Make sure the device stays slippery enough to move smoothly and not cause any irritation when putting it in or taking it out.

In addition, keep checking how the patient is doing overall and change how you manage the airway if needed based on how they're responding. Keeping up with the maintenance of the supraglottic airway device helps make sure the patient's airway stays open and leads to better outcomes.

Removal of SAD

Removing the supraglottic airway device safely and at the right time is really important once the procedure is done and the patient is awake and breathing normally.

• Remove the device gently following the instructions from the manufacturer to avoid hurting the patient or blocking their airway.
• Make sure the patient has enough oxygen and is stable before taking the device out to avoid any breathing problems.
• Keep a close eye on the patient while removing the device for any signs of discomfort or issues like coughing or trouble breathing.
• Give the patient reassurance and support during removal to make it easier for them.
• After taking out the device, check that the patient's airway and breathing are okay.

Removing the supraglottic airway device ends the procedure and gets the patient ready for post-procedure care and recovery.

SAD Post-procedure Care

After removing the supraglottic airway device, keep watching the patient closely for any signs of breathing trouble, blocked airways, or problems from the procedure. Check that the patient's airway, breathing rate, and oxygen levels are okay to make sure they're recovering well. Give extra oxygen if needed to keep their oxygen levels up and help them breathe better during recovery.

Keep an eye out for any signs of problems, like a sore throat or trouble speaking, and deal with them quickly. Give the patient and their family clear instructions on what to watch for and when to get help if something doesn't seem right. Make sure the patient feels comfortable and supported during their recovery, and answer any questions they or their family might have. Good care after the procedure helps the patient get better and makes the whole experience better for everyone involved.

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What are the Common Challenges in using supraglottic airway devices?

Common challenges encountered when using supraglottic airway devices include:

1. Air leaks: Leakage of air around the device leads to inadequate ventilation and compromised oxygenation.
2. Displacement: The device shift from its optimal position, potentially obstructing the airway or impeding effective ventilation.
3. Inadequate seal: Failure to achieve a proper seal between the device and the airway result in air leakage and suboptimal ventilation.
4. Difficulty in insertion: Challenges arise during the insertion process, particularly in patients with anatomical variations or limited mouth opening.
5. Obstruction: Blockage of the device lumen due to secretions, blood, or tissue impede airflow and compromise ventilation.
6. Aspiration: Accidental aspiration of gastric contents or other substances occur if the device fails to seal properly or if there is regurgitation.
7. Patient discomfort: Discomfort or gagging sensations occur, especially if the device is not inserted correctly or if it irritates the throat.
8. Device failure: Rare instances of device malfunction, such as cuff deflation or structural damage, occur, necessitating immediate intervention.
9. Hyperinflation: Overinflation of the device cuff leads to pressure-related complications, including mucosal damage or nerve injury.
10. Difficult airway management: Despite careful assessment and preparation, some patients present with challenging airway anatomy, making device insertion and ventilation more challenging.

When faced with these challenges, it's crucial to act quickly to resolve them. This involves making necessary adjustments such as repositioning the device to ensure it's in the right place, fine-tuning ventilation settings to improve airflow, or even considering other methods to manage the airway if needed. By addressing these issues promptly, ensure optimal patient care and minimize the risk of complications during the procedure.

Supraglottic Airway vs Endotracheal Intubation

Supraglottic airway devices and endotracheal intubation are methods used to secure the airway, but they differ in their indications and techniques. Supraglottic airway devices are often used in basic life support scenarios or when immediate airway control is needed. They sit above the glottis and are inserted blindly into the oropharynx.

In contrast, endotracheal intubation involves passing a tube directly into the trachea through the mouth or nose, providing more precise control over the airway. While supraglottic airway devices are easier to insert and suitable for providers with varying skill levels, endotracheal intubation requires advanced proficiency and is typically performed in more complex situations where mechanical ventilation or airway protection is necessary.

In emergency situations involving children, endotracheal intubation is challenging, necessitating a suitable backup plan. According to clinical studies, supraglottic airway devices offer a valuable alternative for pediatric airway management, characterized by ease of learning and high success rates.

What are the advantages of supraglottic airway devices?

Supraglottic airway devices offer several advantages in airway management. These includes:

• Rapid insertion: Supraglottic airway devices are inserted quickly, making them ideal for situations where prompt airway control is essential, such as in emergencies or when time is limited.
• Minimal training requirement: Compared to endotracheal intubation, the insertion of supraglottic airway devices requires less training and technical skill, making them accessible to a broader range of healthcare providers.
• Reduced risk of trauma: Supraglottic airway devices are less invasive than endotracheal tubes, resulting in lower rates of airway trauma, such as vocal cord injury or dental damage, particularly in patients with difficult airways.
• Versatility: Supraglottic airway devices are used across various clinical settings, from prehospital care to operating rooms, and are suitable for both spontaneous breathing and positive pressure ventilation.
• Tolerance: Patients generally tolerate supraglottic airway devices well, as they do not require paralysis or deep sedation, reducing the risk of complications associated with prolonged anesthesia.
• Lower cost: Supraglottic airway devices are often more cost-effective than endotracheal tubes, making them a preferred option, especially in resource-limited settings.

Supraglottic airway devices provide a valuable alternative for airway management, offering simplicity, efficiency, and versatility across a wide range of clinical scenarios.

Indications of Supraglottic Use

Supraglottic Airway Devices are used when regular methods of managing the airway aren't possible or aren't safe. They're better than putting a tube into the windpipe in some situations because they're faster to put in, less likely to cause injury, and is used when it's hard to predict if intubation will be difficult. They're commonly used during:

• Cardiac arrest: During cardiopulmonary resuscitation, supraglottic airway devices are rapidly inserted to establish ventilation and oxygenation when conventional methods are challenging or time-consuming.
• Respiratory distress: In cases of severe respiratory distress, including asthma exacerbations, acute respiratory failure, or impending airway obstruction, supraglottic airway devices provide a rapid means of maintaining a patent airway and delivering oxygenation and ventilation.
• Unanticipated difficult airways: When difficulty is encountered during endotracheal intubation due to anatomical variations, limited mouth opening, or other factors, supraglottic airway devices offer a quick and effective alternative for airway management.
• Anesthesia induction: Supraglottic airway devices are commonly used as a primary airway management strategy during anesthesia induction, particularly in patients with a low risk of aspiration and anticipated easy airway management.
• Trauma scenarios: In cases of trauma where there are concerns about cervical spine injury or facial trauma, supraglottic airway devices are inserted quickly without the need for neck manipulation, reducing the risk of exacerbating injuries.

Contraindications of Supraglottic Airway

While supraglottic airway devices are widely used in various clinical scenarios, there are certain contraindications and precautions to consider:

1. Presence of a full stomach: Supraglottic airway insertion increase the risk of aspiration in patients with a full stomach, especially if protective airway reflexes are compromised. As a result, caution should be exercised, particularly in patients with a history of recent ingestion of food or fluids.
2. Upper airway obstruction: Supraglottic airway devices are ineffective or contraindicated in patients with severe upper airway obstruction, such as massive oropharyngeal or laryngeal swelling, which impede device placement and compromise ventilation.
3. Anatomical abnormalities: Certain anatomical variations, such as severe facial trauma, distorted airway anatomy, or tumors obstructing the pharynx, pose challenges for proper placement and function of supraglottic airway devices.
4. Risk of regurgitation or aspiration: Patients at high risk of regurgitation or aspiration, such as those with gastrointestinal bleeding, ileus, or altered level of consciousness, are not be suitable candidates for supraglottic airway insertion due to the potential for pulmonary aspiration.
5. Need for positive pressure ventilation: In patients requiring high levels of positive pressure ventilation, such as those with severe respiratory failure or acute respiratory distress syndrome (ARDS), supraglottic airway devices do not provide adequate support and lead to hyperinflation or barotrauma.
6. Inability to achieve adequate seal: Patients with anatomical factors or conditions that prevent the establishment of a proper airway seal between the device and the airway, such as significant oropharyngeal bleeding or excessive secretions, do not be suitable candidates for SAD insertion.

It is essential to carefully assess each patient's clinical condition, airway anatomy, and potential risk factors before considering the use of a supraglottic airway device to ensure safe and effective airway management. Additionally, alternative airway management strategies should be readily available in case of device failure or inadequate ventilation.

What's the difference of extraglottic, supraglottic, and infraglottic airway devices?

Extraglottic airway devices sit outside the glottis and are designed to maintain an open airway without entering the trachea. Extraglottic devices include both supraglottic and infraglottic devices.

Supraglottic devices specifically sit above the glottis, typically within the oropharynx or hypopharynx, and create a seal around the larynx without entering the trachea. 

Infraglottic devices sit below the glottis and extend into the trachea. Endotracheal tubes (ETTs) and tracheostomy tubes are examples of infraglottic airway devices.

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What are the legal implications of using Supraglottic Airway Devices by non-medical professionals?

Using Supraglottic Airway Devices by non-medical professionals carries legal implications that vary based on jurisdiction and context. Non-medical professionals must consider their scope of practice, ensuring they don't exceed authorized duties. They're held to a reasonable standard of care, requiring adequate training to use SADs safely and effectively. Obtaining informed consent and abiding by Good Samaritan laws are essential. While these laws provide legal protections, liability arises from reckless behavior or negligence. Ultimately, adherence to training, consent, and legal standards helps mitigate legal risks associated with SAD use by non-medical professionals.

How can practitioners obtain certification in the use of Supraglottic Airway Devices?

Practitioners can obtain certification in the use of Supraglottic Airway Devices (SADs) through various courses:

1. Basic Life Support Courses: Many BLS certification courses, such as those offered by the American Heart Association (AHA) or the American Red Cross, include training on SADs as part of their curriculum. Completing these courses and passing the exams leads to certification in basic airway management, including the use of SADs.
2. Advanced Cardiac Life Support Courses: ACLS certification courses typically cover advanced airway management techniques, including the use of SADs, for healthcare providers. These courses are suitable for practitioners seeking more comprehensive training in airway management beyond basic BLS certification.
3. Specialized Airway Management Courses: Some organizations offer specialized training programs focused specifically on airway management, including the use of SADs. These courses are designed for healthcare professionals seeking advanced skills or certification in airway management.
4. Continuing Education and Professional Development: Other practitioners pursue continuing education opportunities and professional development activities focused on airway management. These include workshops, seminars, online courses, or hands-on training sessions specifically addressing the use of SADs.

Sources:

• Kwanten LE, Madhivathanan P. Supraglottic airway devices: current and future uses. Br J Hosp Med (Lond). 2018 Jan 2;79(1):31-35. doi: 10.12968/hmed.2018.79.1.31. PMID: 29315046.
• Van Zundert A, Brimacombe J, Kamphuis R, Haanschoten M. The anatomical position of three extraglottic airway devices in patients with clear airways. Anaesthesia. 2006 Sep;61(9):891-5. doi: 10.1111/j.1365-2044.2006.04745.x. PMID: 16922757.
• Sanders JE, Spina LA. Supraglottic airway devices for pediatric airway management in the emergency department. Pediatr Emerg Med Pract. 2020 Oct;17(10):1-20. Epub 2020 Jul 2. PMID: 33001595.

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