Rescue Me

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Extraglottic devices are often term "rescue devices."  And I can't decide whether this is a term that glorifies or degrades.  While yes they can often save your tail after a failed attempt at direct or video laryngoscopy, they can do so much more. Running a code in a resource limited setting with 2 providers? The gold standard of 2 person bag valve mask technique ain't going to be an option for you.  And you think you can hold C-E mask seal while bagging for 20 min?  If you can, you must have hands that rival the late great Andre Rene Roussimoff...

Have a patient's mental status decline rapidly in flight?  Yes, you can intubate in flight.  But your success rate isn't going to be as high as in the ED where you aren't crouching in relatively cramped quarters, hunched over, traveling at 120 mph with a 25 mph cross wind and the interminable turbulence of a summer afternoon.

And, with many of the devices now, the extraglottic device can serve as a channel through which you can place an endotracheal tube passed the vocal cords and into the promised land of the patient's trachea (I'm looking at you intubating LMA and i-Gel).

So yes, they can save your tail after a failed VL or DL view but they can also temporize a patient's airway straight out of the gait and serve as a means by which to deliver and ET tube into a patient's trachea.   Most of these devices are dead simple to use.  But as with all procedures there are nuances to their use that can help you optimize their performance.  In the videos below, Dr. Carleton will go over some tricks and tips that will help you properly place and use the seemingly more challenging of the "rescue devices" on Air Care and in the SRU - the intubating LMA.  We will have more posts in the future on other rescue devices (specifically the i-Gel and how to intubate through the i-Gel).

Important to know, but not specifically covered in the videos, are the patient factors that can predict difficulty in placing and using an extraglottic device.  They are remembered through the mnemonic - RODS (1)

  • R - Restricted mouth opening - will make physically getting the EGD in place challenging
  • O - Obstruction (at the larynx or below) - will make it impossible to ventilate as there is still obstruction below the EGD
  • D - Disrupted or Distorted airway - will make it difficult for the device to "seat" or get a good seal
  • S - Stiff lungs - (i.e. asthma or pulmonary edema) will make gas exchange and ventilation difficult as you might not be able to generate sufficient pressure to overcome the resistance or lack of compliance in the lung tissue

References

  1. Walls, R. & Murphy, M. (2008) Identification of the Difficult Airway. Manual of Emergency Airway Management, 3rd ed. p 90.