Pediatrics

Jan. 03, 2019

Increasingly, extraglottic airway devices are used for adult trauma patients in place of traditional methods of intubation for oxygenation and ventilation. They are utilized in different locales — in the prehospital setting, or in the hospital as a backup device for more difficult airways — but for the same reason: greater efficiency and simplicity.

"Previously, patients in whom these devices are now utilized would have been intubated for oxygenation and ventilation, but extraglottic devices have been found to be safe and expeditious in the field," says Benjamin J. Sandefur, M.D., an emergency physician at Mayo Clinic in Rochester, Minnesota.

As airway courses have become increasingly available for providers, extraglottic devices have penetrated more health systems. Now, Dr. Sandefur says, it's routine for patients with an extraglottic device in place to arrive at any emergency department.

Extraglottic airway device types and risks

Many types of extraglottic devices have come onto the market with distinct seals, positioning recommendations, and reusability and aspiration control features, according to a study published in the August 2017 issue of Medical Devices: Evidence and Research. The main device categories, however, are cuffed and uncuffed. Though extraglottic devices are sometimes used as a primary airway device by anesthesiologists during surgery, generally their use in emergency care is temporary.

Risks in use of extraglottic devices include:

• Failure: The primary risk is inadequate oxygenation and ventilation for the patient.
• Leaks: If not appropriately seated, these devices can leak, resulting in inadequate ventilation.
• Aspiration: As with any airway procedure, there is a risk of aspiration with extraglottic devices, but risks are not nearly as high as providers sometimes fear they may be, says Dr. Sandefur.
• Tongue engorgement and pharyngeal edema: If the pressure in a cuffed extraglottic device, such as the King LT-D, is too high or the device is used longer than two hours in a patient, tongue engorgement and pharyngeal edema can result, making exchange to an endotracheal tube difficult or impossible.

What to do when a patient arrives with an extraglottic airway device

When an adult patient in whom an extraglottic device has been placed arrives at your hospital, Dr. Sandefur recommends the following steps:

1. Assess the function of the extraglottic device in place. Determine whether the device is seated properly and is providing appropriate oxygenation and ventilation to the patient. Evaluate via capnography whether the patient's chest is rising properly, breath sounds are present and there is a positive return of carbon dioxide. Check for air leaks and assess inflation pressure, if applicable.
2. If the device is functioning properly, allow it to remain in place en route to tertiary care. If it's providing ventilation and oxygenation and appropriately seated, the device is reasonably stable but does require close monitoring and frequent assessment of whether it's functioning appropriately.
3. For nonfunctioning devices, the airway should be exchanged in the emergency department. All efforts should be made to avoid attempting an airway exchange at the bedside without appropriate resources on hand, says Dr. Sandefur, but a truly nonfunctioning device should be immediately removed and the airway managed and secured by alternate means. Options include endotracheal intubation, placing an alternative extraglottic device or performing a front-of-neck access (FONA), such as a surgical cricothyrotomy.

Transfer and extraglottic devices

In the trauma setting, the vast majority of individuals requiring emergency measures such as extraglottic devices to secure their airways should be transferred to a higher level of care, usually a Level I Trauma Center. A scenario in which a patient may arrive at a critical access hospital and stay at that facility occurs when providers determine the patient to have unsurvivable injuries and require comfort care only.

If providers at your hospital determine that a patient with this type of device will be transferred, begin discussions with the receiving tertiary care facility. For facilities within the Mayo Clinic Health System, telemedicine also is available from 11 a.m. until 11 p.m. Central time to consult on-screen with Mayo Clinic emergency providers as resources and transport are planned.

Upon arrival to tertiary care, a multidisciplinary team consisting of physicians from emergency medicine, trauma surgery and anesthesiology consults and reaches a consensus on the type of extraglottic device exchange to be made.

Here are the exchange possibilities:

• Removal and orotracheal intubation
• Orotracheal intubation utilizing a video laryngoscope and exchange catheter with extraglottic device in situ with cuff deflated
• Flexible endoscopic exchange utilizing an Arndt airway exchange catheter
• Placement of a FONA

Populations at risk of difficult airway exchange include patients with significant head and neck trauma, those in whom the device was placed because of difficult intubation and those in whom a cuffed extraglottic device, such as the King LT-D, has been in place for a prolonged period (more than two hours) or with high cuff pressures (more than 60 mm H₂O).

For more information

Sharma B, et al. Extraglottic airway devices: Technology update. Medical Devices: Evidence and Research. 2017;10:189.