Notfallmedizin

Anaesthesist 2014 · 63:589–596 M. Bernhard1 · W. Beres2 · A. Timmermann3 · R. Stepan4 · C.-A. Greim5 · U.X. Kaisers6 · DOI 10.1007/s00101-014-2348-1 A. Gries1 Published online: 2. Juli 2014 1 , University Hospital of Leipzig, Leipzig © Springer-Verlag Berlin Heidelberg 2014 2 Department of Anaesthesiology and , Main Klinik Ochsenfurt, Ochsenfurt 3 Department of Anaesthesiology, Pain Therapy, Intensive Care Medicine and , DRK Kliniken Berlin Westend und Mitte, Berlin Redaktion 4 Department of Public Health, Fulda County, Fulda A. Gries, Leipzig 5 Department of , Intensive Care Medicine and Emergency Medicine, Hospital of Fulda, Fulda V. Wenzel, Innsbruck 6 Department of Anesthesiology and Intensive Care Medicine, University Leipzig, Medical Faculty, Leipzig Prehospital using the laryngeal tube An emergency department point of view

Securing the airway and maintaining ox- Studies describing the successful use of mittee of the Medical Faculty of Leipzig, ygenation and ventilation represent es- the laryngeal tube in the prehospital setting Germany. Single cases were documented sential life-saving strategies in emergen- sound promising [9, 10, 22]. However, the initially after ED admission. The case se- cy medicine [1, 2, 3, 40]. Depending on results of these studies and of case reports ries was evaluated retrospectively, was not the experience of the person performing were not reported by an independent ob- preregistered, and written informed con- the procedure and on the individual in- server and, therefore, reporting bias could tent could not be obtained. tubation conditions, endotracheal intuba- be possible [11, 22]. Only one prospective, tion (ETI) is still considered to be the gold randomized study has confirmed that the Results standard [4, 5, 40]. LTS-D is comparable to ETI in the prehos- Failed prehospital ETI is a common pital setting [41]. Indeed, the successful use Patient characteristics and the clinical occurrence and associated with increased of the laryngeal tube depends on individu- problems associated with the use of the mortality. Reliable airway devices such as al performance in carrying out the airway LT are described in detail in the follow- supraglottic airways (SGA) are needed for maneuver (e.g., skill, experience, and qual- ing section. rescuers who are less experienced in ETI ification). The following case series pres- [2, 3, 40]. The different types of larynge- ents the problems and complications upon Case report 1 al mask airway (LMA) and the laryngeal arrival in the emergency department de- tube have been reported as acceptable al- scribed by emergency physicians indepen- A 50-year-old patient fell down the stairs. ternative devices [6, 7, 8, 40]. dently of the prehospital emergency per- He was initially in stable cardiopulmo- The laryngeal tube was introduced as sonnel. These observations raise questions nary condition but unconscious according an alternative to the LMA for managing concerning the safety and usefulness of a to the Glasgow Coma Scale (GCS), with difficult airway situations, both in the hos- laryngeal tube in the prehospital setting. a GCS of 3. An EMS physician inserted a pital and in the prehospital setting. The la- LTS II without attempting ETI first. Cap- ryngeal tube then became rapidly estab- Methods nography was not used at the scene or dur- lished in many emergency medical ser- ing transport. Upon arrival in the ED, the vices (EMS) and its use was implemented Clinical observations were made in a non- patient was severely cyanotic. Upon hospi- in international guidelines [2]. The laryn- consecutive series of patients between tal admission, the patient developed asys- geal tube has now been modified so that 2007 and 2012. All patients were admit- tole. Cardiopulmonary (CPR) different versions of this device are used ted to the resuscitation rooms of emer- was initiated immediately. End-expiratory in the prehospital setting [laryngeal tube gency departments (ED) at tertiary care carbon dioxide (etCO2) could not be detect- (LT), disposable version (LT-D), larynge- hospitals (University Hospital of Heidel- ed using after handing the pa- al tube suction mark II (LTS II), and dis- berg, Hospital of Fulda, University Hospi- tient over in the ED. Considering misplace- posable version (LTS D), all VBM, Sulz, tal of Leipzig). Reporting data in the pres- ment and expecting an endotracheal posi- Germany]. ent form was approved by the ethics com- tion, the LT was removed immediately, and

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blade. The patient survived without any ry and metabolic acidosis (pH 6.6, paCO2 neurological sequelae. 169 mmHg, paO2 89 mmHg, base excess −22 mmol/l). The patient was transferred Case report 3 to the cardiac catheter laboratory for im- mediate PCI but died of multi-organ fail- A 65-year-old patient (body mass index ure on hospital day 7 on the ICU. 57 kg/m2) suffered from out-of-hospital cardiac arrest. A LTS II was inserted initial- Case report 5 ly by an EMS physician without attempting ETI first. ROSC was achieved in the pre- A 25-year-old patient suffered a high- hospital setting after CPR. However, cap- speed motorcycle accident and was found nography was not used in the prehospital with a GCS 5. After failed ETI within two setting. Upon arrival in the ED, peripheral attempts and aspiration of a considerable oxygen saturation could not be detected al- amount of blood from the oropharynx, a though blood pressure and heart frequency LT was placed by the EMS physician. The were normal. A clearly audible ventilation patient was then handed over to an air res- synchronous leak was perceived alongside cue team. Due to the information reported Fig. 1 8 Swelling of the tongue after brief dura- the inserted LT in the ED. The end-expi- by the first EMS team, the physician of the tion of ventilation after a laryngeal tube was in- ratory minute volume was low (3.5 l/min). air rescue system abstained from switching serted in the prehospital setting After introduction of emergency anesthe- the LT to a . Mechanical venti- endotracheal intubation was performed sia, the LT was removed and laryngosco- lation was assumed to be sufficient for the without any difficulty. Return of spontane- py showed a severely cyanotic and thick- patient and difficult ETI conditions were ous circulation (ROSC) was achieved with- ened tongue; the posterior pharyngeal wall suspected. During air transport, the pa- in the following 3 min of CPR. Immediate- was swollen, and blood had covered the en- tient suffered from cardiac arrest and ar- ly after endotracheal intubation, blood gas tire oropharynx. Conventional laryngos- rived in the ED undergoing CPR with in- analysis showed combined severe respira- copy demonstrated a Cormack–Lehane adequate ventilation. In the ER, ETI was tory and metabolic acidosis (pH 6.7, pa- grade IV. ETI was performed successfully performed immediately and without any CO2 164 mmHg, paO2 62 mmHg, base ex- with a McCoy blade. Thereafter, a CT scan problems. Owing to an instable chest with cess −21 mmol/l). CT scan demonstrated was performed and confirmed a pulmo- several rib fractures, bilateral tension pneu- extensive brain edema, a massively swollen nary embolism. The patient died of right mothorax was clinically suspected and im- stomach, abnormally large amounts of air ventricular failure in the course of the next mediately treated by inserting chest tubes. in the small and large intestines, and mas- few days on the ICU. The CT scan confirmed a thoracic trauma sive aspiration. The only found was with pneumothorax and severe aspiration. a fracture of the spinous process of the sev- Case report 4 The patient died of abdominal and thorac- enth cervical vertebra that did not com- ic in the ED. promise the spinal cord. The patient died A 55-year-old patient suffered from out- 6 days after being admitted to the intensive of-hospital cardiac arrest. After CPR was Case report 6 care unit (ICU). initiated by bystanders, a paramedic in- serted a LTS II without attempting ETI A 22-year-old patient was the victim of a Case report 2 first. After 20 min of CPR and after arrival high-speed motor vehicle accident. Ini- of an EMS physician, the patient achieved tial GCS was 5 but his respiration and car- A 55-year-old patient suffered from an ROSC. During the prehospital course, a diopulmonary condition were stable. Still out-of-hospital cardiac arrest and asso- clearly audible ventilation synchronous entrapped in his vehicle, a LTS II was in- ciated fall. A LT was inserted by a para- leak was perceived alongside the inserted serted by an EMS physician through the medic without attempting ETI first. The LT; however, no attempts were made to window on the driver’s side. During ex- arriving EMS physician refrained from manage this problem. After arrival in the trication and 20 min after insertion, the switching over to a tracheal tube in the ED, this sound was remarkable, the abdo- LTS II was subsequently dislocated. It was field. However, as a result of using LT dur- men was obviously swollen, and mechani- not possible to reinsert the LTS II. Laryn- ing the prehospital interval of 45 min, the cal ventilation was inadequate [low etCO2, goscopy demonstrated massive swelling of patient’s tongue had swollen considerably low end-expiratory minute volume (2.4 l/ the throat and vocal cords. The patient’s (. Fig. 1). After ED admission, the LT min)]. The LT was removed immediate- cardiopulmonary condition worsened was removed and subsequent laryngosco- ly, and subsequent ETI proved to be very and he ultimately suffered cardiac arrest. py proved to be very difficult (Cormack– easy (Cormack–Lehane grade I). Due to Cricothyroidotomy was performed, and Lehane grade IV), most probably as a con- hypoventilation during the prehospital the patient arrived in the ED under pro- sequence of the swollen tongue. ETI was course, the initial blood gas analysis dem- longed CPR. ROSC could not be estab- performed successfully by using a McCoy onstrated a combined severe respirato- lished in the ED.

590 | Der Anaesthesist 7 · 2014 Abstract · Zusammenfassung

Case report 7 Anaesthesist 2014 · 63:589–596 DOI 10.1007/s00101-014-2348-1 © Springer-Verlag Berlin Heidelberg 2014 A 32-year-old patient suffered from severe M. Bernhard · W. Beres · A. Timmermann · R. Stepan · C.-A. Greim · U.X. Kaisers · A. Gries head injury with midfacial fractures after Prehospital airway management using the laryngeal tube. a fall from a height of 8 m. The patient was An emergency department point of view breathing spontaneously and in stable car- diopulmonary condition with a GCS of 6. Abstract After induction of emergency , Background. Competence in airway man- incorrect placement of the laryngeal tube in ETI attempts failed due to blood in the agement and maintenance of oxygenation the pharynx, tongue and pharyngeal swell- and ventilation represent fundamental skills ing with subsequently difficult laryngoscopy, oropharynx, and thus the EMS physician in emergency medicine. The successful use of and inadequate ventilation due to unrecog- inserted a LTS II. Upon arrival in the ED, laryngeal tubes (LT, LT-D, LTS II) to secure the nized airway obstruction and tension pneu- using manual bag-valve ventilation, the airway in the prehospital setting has been mothorax. patient’s ventilation was inadequate due published in the past. However, some compli- Conclusion. Although the laryngeal tube is to LT displacement, as verified by low ex- cations can be associated with the use of a la- considered to be an effective, safe, and rapid- piratory minute volume. ETI was success- ryngeal tube. ly appropriable supraglottic airway device, it Methods. In a nonconsecutive case series, is also associated with adverse effects. In or- ful after inducing anesthesia with neuro- problems and complications associated with der to prevent tongue swelling, after initial muscular blockade and aspirating blood the use of the laryngeal tube in prehospi- prehospital or in-hospital placement of laryn- from the oropharynx. Whole-body MSCT tal emergency medicine as seen by indepen- geal tube and cuff inflation, it is important to confirmed the diagnosis of severe head in- dent observers in the emergency room are adjust and monitor the cuff pressure. presented. jury with a dismal prognosis. The patient Article published in English Results. Various problems and possible com- died on the ICU. plications associated with the use of a la- Keywords ryngeal tube in eight case reports are re- Respiration, artificial · Emergency medical Case report 8 ported: incorrect placement of the larynge- service · Endotracheal intubation · al tube in the trachea, displacement and/or Professional competence · Adverse effect A 70-year-old patient suffered from out- of-hospital cardiac arrest. A LT was in- Prähospitales Atemwegsmanagement mithilfe des serted by a paramedic without attempting Larynxtubus. Sicht der Notaufnahme ETI first. The patient achieved ROSC af- ter arrival of an EMS physician and a CPR Zusammenfassung Hintergrund. Die sichere Beherrschung des nichtkorrekte Platzierung des Larynxtubus im duration of 5 min. During the transport, Atemwegsmanagements sowie die Aufrecht­ Pharynx, Zungen- und Pharynxschwellung however, the patient’s ventilation became erhaltung einer Oxygenierung und Ventila- mit nachfolgender schwieriger Laryngo­ increasingly difficult, with a peak airway tion sind fundamentale Fähigkeiten in der skopie, inadäquate Ventilation durch uner- pressure of >40 cmH2O and a drop in pe- Notfallmedizin. Im prähospitalen Setting kannte Atemwegsobstruktion und Span- ripheral oxygen saturation. Upon arrival wurde die erfolgreiche Anwendung von La­ nungspneumothorax. in the ED, ventilation was inadequate and rynxtuben (LT, LT-D und LTS II) zur Atemwegs­ Schlussfolgerung. Obwohl der Larynxtubus sicherung wiederholt publiziert. Jedoch kön- als effektive, sicher und rasch anwendbare airway obstruction was highly suspect- nen auch Komplikationen bei der Anwen­ supraglottische Atemwegshilfe angesehen ed. The LT was removed immediately and dung des Larynxtubus auftreten. wird, können schwere Nebenwirkungen ein- the cause of the ventilation problem rec- Methode. In einer nichtkonsekutiven Fall- treten. Um eine Zungenschwellung nach prä- ognized: the LT and the trachea were ob- serie werden die mit der Anwendung des La­ oder innerklinischer Einlage eines Larynx- structed by chunks of bread. The bread rynxtubus assoziierten Probleme und Kom- tubus zu verhindern, sollte der „Cuff“-Druck was extracted from the oropharynx using plikationen durch unabhängige Beobachter gemessen und angepasst werden. aus der Notaufnahme berichtet. a Magill forceps and ETI was performed Ergebnisse. Es wird von folgenden Prob- Schlüsselwörter with no difficulty. The patient was trans- lemen und Komplikationen berichtet, die Beatmung, künstlich · Rettungsdienst · ferred to the ICU and survived. bei Anwendung des Larynxtubus in 8 Fällen Endotracheale Intubation · Professionelle auftraten: nichtkorrekte Platzierung des La­ Kompetenz · Nebenwirkungen Discussion rynxtubus in der Trachea, Verrutschen bzw.

Securing the airway and effectively man- recommended [3]. Currently, SGA have inserting SGA in patients suffering from aging oxygenation and ventilation play a shifted into the focus not only as an al- out-of-hospital cardiac arrest [47]. central role in emergency medicine. Up ternative for difficult ETI but also to re- Most studies investigating SGA have to now, ETI has been considered the gold place conventional bag–valve mask venti- been performed on airway trainers or in standard for securing the airway. Depend- lation [12]. However, a recently published routine clinical situations in anesthetized ing on the experience of the person per- secondary analysis of data from the mul- patients [13, 14, 15, 17, 18, 42]. In prehos- forming the procedure, however, excep- ticenter Resuscitation Outcome Consor- pital research settings, both EMS physi- tions are sometimes made to applying the tium (ROC) PRIMED trial showed that cians and paramedics have used the la- gold standard and alternative methods are outcome was better after ETI than after ryngeal tube [19, 20, 21, 43, 44]. The inser-

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Tab. 1 Complications associated with us- (caused by tension of the rigid tube of the this should only be the “last resort” treat- ing a supraglottic airway device ventilator) can render ventilation instant- ment and in an individual case. In the Insertion unsuccessful ly impossible. Deep esophageal insertion majority, however, high-flow oxygen via a Not inserted deeply enough (danger of a of a LTS II that is too large may result in face mask is sufficient to bridge the time valve mechanism) impossible ventilation (ventilation orifices until the patient can be reached for prop- Impossible or inadequate ventilation obstructed by esophageal mucosa; case 7). er airway management. (unrecognized) displacement If the laryngeal tube is not correctly placed As reported for other devices, the (unrecognized) endotracheal obstruction in the esophagus or the cuff of the LT/LTS tongue and laryngeal swelling in cas- Tongue swelling is blocked at the level of the larynx, the es 2, 3, and 6 do not represent a larynge- Bleeding and swelling in the oropharyngeal laryngeal structures can be compressed al tube-specific problem [32, 33, 34, 35, and laryngeal areas or the airways completely obstructed [16, 43]. The mechanism ultimately underly- 44]. Subsequently, the air that is insufflat- ing the tongue swelling is still unknown tion technique is described as being sim- ed exerts uncontrolled airway pressure on (e.g., venous stasis, secondary tissue ede- ple and easy to learn, and the rate of cor- the upper esophageal sphincter [16]. If the ma). However, tongue swelling associat- rectly and safely placing the laryngeal tube pressure on the upper esophageal sphinc- ed with the use of a laryngeal tube is al- (here: LTS-D) is reported to be high even ter drops rapidly during cardiac arrest, air most always related to inappropriate cuff for inexperienced personnel [22]. Howev- will inevitably be forced into the stom- pressure. Using the amount of air indi- er, various and severe complications have ach [31]. In such situations, any subse- cated with color markings on the syringe been observed in using the laryngeal tube quent airway pressure that is applied will may result in excessive cuff pressure above [9, 16, 17, 44]. be directed to the esophagus and ventila- 100 mmHg. Such high cuff pressure can The main point of presenting this case tion will be inadequate. Furthermore, the interfere with both the arterial blood sup- series is to show that laryngeal tube-asso- lower part of the LT/LTS can bend such ply to the tongue and venous drainage. ciated problems can occur and that the that the distal cuff is located in the larynx Therefore, after prehospital or in-hospital provider must be aware of all the prob- instead of the esophagus and the air flow initial placement of a laryngeal tube and lems and needs to deal with them. There- is blocked [16, 28]. This would also cause cuff inflation, it is important to adjust and fore, the problems described in this case stomach insufflation [28]. If air is direct- monitor cuff pressure. series are related to the following: ed into the stomach due to obstruction, Furthermore, blood in the oropharynx F laryngeal tube, regurgitation and aspiration are inevitable can be the result of traumatic insertion of F (lack of) (e.g., capnography), as the upper cuff in the pharynx prevents the laryngeal tube, particularly if the la- F user (deficits), and air from flowing out through the mouth. ryngeal tube was inserted without actively F management of patients with laryn- These kinds of obstruction apply in gen- creating sufficient retropharyngeal space geal tube in situ upon hospital admis- eral for all versions of the laryngeal tube. by means of a chin lift manoeuver or with sion. It is also possible to misplace the tip of a laryngoscope. the laryngeal tube in the piriform sinus, Second, training for assessing/control- First, the risks of using the laryngeal tube which can also result in leakage, gastric in- ling/monitoring correct positioning and presented in this paper should be applied sufflation, and even airway trauma with adequate ventilation is as important as in- in the decision-making process, since a swollen pharyngeal wall or tongue [16, serting a SGA. In case 1, insufficient air- SGA-associated problems can cause com- 44]. Therefore, laryngeal tubes with the way management is described and, retro- plications (. Tab. 1). Other studies re- possibility to insert a gastric tube should spectively, the fatal outcome could have port incorrect positioning of laryngeal be preferred [40]. If problems are encoun- been avoided if capnography had been tubes during in-hospital and prehospital tered in inserting a gastric tube soon af- used. Thus, auscultation and capnog- conditions [28, 42, 44]. Keeping this in ter a LTS has been placed, it can be as- raphy need to be integrated into train- mind, the findings in case 1 suggest mis- sumed that the lower part of the LTS is ing programs. Ultimately, capnography placement, speculatively in the trachea. In bent, thus, causing this obstruction, and should be employed whenever the airway fact, owing to its construction, the laryn- the LTS must be inserted again. However, needs to be secured [38]. Since 2007, an geal tube can cause hypoxia when the dis- adequate ventilation must be controlled EMS in Germany can be held liable if res- tal end is incorrectly positioned in the tra- by auscultation and capnography after in- cue vehicles are not equipped with cap- chea or it is misplaced in the glottis level, serting any device (case 1). nography [27]. Cases 1 and 3 show, how- both not recognized. Difficulties in initial tube positioning, ever, that capnography is still not always Other kinds of obstruction are also tube dislocation, and aspiration (case 6) utilized, even today. Unrelated to the use possible using laryngeal tubes [16]: The were reported in 25, 13, 5%, respective- of a specific device, a prehospital provid- use of a cervical immobilization collar can ly [43, 44]. ETI is the gold standard for er must detect incorrect placement by us- cause caudal herniation of the pharynge- airway management in trauma patients ing capnography, and neglecting to do this al cuff of the LT, with subsequent obstruc- [30] and SGA may be a useful strategy in plays a significant role in the catastrophic tion of the ventilation orifices. Rotation entrapped patients. However, in an en- outcome here, possibly independently of of the LTS II along its longitudinal axis trapped patient under worse conditions, the airway device being employed.

592 | Der Anaesthesist 7 · 2014

Notfallmedizin

Third, not all EMS providers have suf- dividual clinical expertise and airway man- geal tube that has been successfully insert- ficient expertise in airway management agement skills. ed and is providing adequate ventilation, (ETI and SGA). In Germany,the results EMS physicians, in particular, who while being continuously monitored by of a survey published 7 years ago report- do not practice airway management dai- capnography, should be critically weighed ed that 18% of nonanesthesiological EMS ly, should be sensitized to the presented against the option of removing it to enforce physicians had only performed 20 ETI problems in this case series. This also ap- the gold standard ETI. The decision to re- procedures and 53% had performed 20– plies to paramedics who are increasing- move the laryngeal tube should depend on 100 such procedures in the in-hospital ly employing laryngeal tubes as part of the given situation, the success of oxygen- setting [23]. Furthermore, the individu- their “extended skills”. This involves more ation and ventilation, and the patient’s indi- al EMS physician only performed an ETI than mastering the clinical skills for per- vidual risk profile. Numerous factors affect procedure twice per month during air res- forming an ETI or inserting SGA. Howev- this decision, not least the experience of the cue missions and only every 1.4 months er, keeping in mind that manikin training provider. However, if problems occur after during ground rescue missions [24]. Suf- alone was reported to be insufficient, this inserting a laryngeal tube (A-Problem), the ficient skills and experience—especially in represents a dilemma since the laryngeal provider must recognize and resolve them, airway management—cannot be achieved tube has not been comprehensively and even though this means removing the la- through work in the field alone [23, 24]. regularly applied for routine anesthesia or ryngeal tube and switching to a tracheal Moreover, an older evaluation showed in other clinical procedures [29]. tube (cases 1 and 5). If problems with ven- that 42% of nonanesthesiological EMS It should be kept in mind that, in line tilation persist after replacing the larynge- physicians have no practical experience with guidelines in Germany for prehospi- al tube by an ETI, typical reversible causes in using SGA [23]. tal airway management of patients suffer- should be considered and treated (e.g., ten- Presently, there is no national regula- ing from multiple trauma, if oxygenation sion pneumothorax, B-Problem). In partic- tion concerning the number of successful and ventilation are adequate and the pro- ular for patients suffering from multiple in- ETI procedures necessary before a physi- vider is uncertain about his/her airway juries, especially from thoracic injury and/ cian is allowed to function as a prehospi- skills, patients can be transferred with a or apparent aspiration (case 6) who may tal provider in Germany [25, 26, 40]. Like- “scoop and run” strategy to the hospital require high airway pressures, it should be wise, practical experience in using SGA has without inserting endotracheal tube or considered strictly unacceptable to refrain not been defined in the emergency med- any kind of SGA [30]. from ETI because of inexperience in favor icine curriculum. The corresponding re- Fourth, management of the patient of a seemingly easier procedure for secur- quirements for paramedics also lack such treated with laryngeal tube upon hospital ing the airways [36]. specifications. A recently published state- admission should be highlighted: Perceiv- SGA often only represent a temporary ment of the German Society of Anaesthe- ing the risk potential in a given situation is solution. At the latest upon hospital ad- siology and Intensive Care Medicine gives particularly relevant for the staff who take mission, even a well-positioned larynge- for the first time clear recommendations over. Upon arrival at the emergency scene al tube that is ventilating the patient suf- for prehospital qualification of paramed- or ED, the new staff immediately needs to ficiently will need to be replaced by a tra- ics and out-of-hospital physicians con- assess oxygenation and ventilation and take cheal tube with respect to a presumably cerning endotracheal intubation and SGA preparatory measures for reintubation. It longer period of ventilation and/or likely (e.g., 100 ETI under supervision, then 10 is undoubtedly important that alternative difficult with high- ETI per year, 10 SGA under supervision, strategies are available for securing the air- er PEEP. When the airway conditions are and 3 SGA per year) [40]. This statement way when difficult ETI conditions are al- indeed difficult, a tracheotomy may need is supported by one from the Association ready known from prehospital manage- to be considered. The best procedure must of Anaesthetists of Great Britain and Ire- ment [45]. In addition and as demonstrat- be gauged in each individual case with re- land, which has also provided recommen- ed in this paper, the use of laryngeal tubes spect to the individual situation (e.g., vid- dations for the qualification of prehospi- as the primary airway in the field can be eolaryngoscope) [46]. tal airway providers [48]. In particular, the associated with relevant, subsequent prob- We know that the presented case reports use of bag–valve mask ventilation, SGA, lems. Several cases (cases 1–4, 8) demon- could be discussed controversially. A limi- and even rapid-sequence induction in rou- strate this clearly. Standard procedures for tation of our study is the nature of the pre- tine clinical management such as in anes- managing difficult airways should be per- sented nonconsecutive case series. There- thesiology, intensive care medicine, or pre- formed in the ED and physicians who are fore, these case reports only present exam- hospital and in-hospital emergency med- experienced in airway management should ples of such complications and describe icine settings should be a prerequisite for be involved in primary care. what happened when the complications successful use of these methods. Regular After a laryngeal tube has been insert- were not treated very well. As another con- training both in airway management and ed by a former provider, the EMS physi- sequence, care must be taken in compar- in routinely inducing anesthesia should be cian or the ED staff that takes over must ing our findings with the incidence of air- considered mandatory for EMS physicians. decide whether to keep it in place or to re- way catastrophes in other studies [39]. Al- Indeed, the problems in these case reports place it by an endotracheal tube. In the au- though this question cannot be addressed might be a consequence of insufficient in- thors’ view, the decision to replace a laryn- owing to the design of this study, the find-

594 | Der Anaesthesist 7 · 2014 ings are essential: Because this may consti- Compliance with ethical 15. Kurola J, Harve H, Kettunen T et al (2004) Airway management in cardiac arrest-comparison of the tute the tip of the iceberg, insufficient air- guidelines laryngeal tube, and bag–valve way management is an actual problem at mask ventilation in emergency medical training. the scene and SGA should not be claimed Conflict of interest. M. Bernhard, W. Beres, A. Tim- Resuscitation 61:149–153 16. Dengler V, Wilde P, Byhahn C et al (2011) Prehospi- to be helpful in these situations. In this con- mermann, R. Stepan, C.-A. Greim, U.X. Kaisers, and A. Gries state that there are no conflicts of interest. The tal airway management of laryngeal tubes. Should text, it is hazardous not to recommend ac- accompanying manuscript does not include studies on the laryngeal tube S with gastric drain tube be quiring practical skills for the use of SGA in humans or animals. preferred in emergency medicine? Anaesthesist 60:135–138 a prehospital setting. As another limitation 17. Mihai R, Knottenbelt G, Cook TM (2007) Evaluation of this nonconsecutive case series, which References of the revised laryngeal tube suction: the laryn- is given from the emergency department’s geal tube suction II in 100 patients. Br J Anaesth 99:734–739 point of view, the clinical background and 1. Berlac P, Hyldmo PK, Kongstad P et al (2008) Pre- hospital airway management: guidelines from a 18. Russo CS, Wilcox CL, House HR (2007) The larynge- the level of experience of each of the in- task force from the Scandinavian society of anaes- al tube device: a simple and timely adjunct to air- volved prehospital emergency physicians thesiology and intensive care medicine. Acta An- way management. Am J Emerg Med 25:263–267 19. Heuer JF, Barwing J, Eich C et al (2010) Initial venti- or paramedics is unknown. aesthesiol Scand 52:897–907 2. Deakin CD, Nolan JP, Soar J et al (2010) European lation through laryngeal tube instead of face mask resuscitation council guidelines for resuscitation in out-of-hospital cardiopulmonary arrest is effec- Conclusion 2010. Section 4. Adult . Re- tive and safe. Eur J Emerg Med 17:10–15 suscitation 81:1305–1352 20. Schalk R, Byhahn C, Fausel F et al (2010) Out-of- 3. Paal P, Herff H, Mitterlechner T et al (2010) An- hospital airway management by paramedics and Laryngeal tubes are considered to be ef- aesthesia in prehospital emergencies and in the emergency physicians using laryngeal tubes. Re- fective, safe, and rapid SGAs. Operators emergency room. Resuscitation 81:148–154 suscitation 81:323–326 21. Wiese CH, Semmel T, Müller JU et al (2009) The use must be aware of the operator- und pro- 4. Komatsu R, Kasuya Y, Yogo H et al (2010) Learning curves for bag-and-mask ventilation and orotra- of the laryngeal tube disposable (LT-D) by para- cedure-related complications of larynge- cheal intubation. An application of the cumulative medics during out-of-hospital resuscitation—an al tubes, and they must recognize them. sum method. Anesthesiology 112:1525–1531 observational study concerning ERC guidelines 2005. Resuscitation 80:194–198 In order to prevent tongue swelling, after 5. Konrad C, Schüpfer G, Wietlisbach M, Gerber H (1998) Learning manual skills in anesthesiology: is 22. Scheller B, Walcher F, Byhahn C et al (2010) Laryn- initial prehospital or in-hospital place- there a recommended number of cases for anes- geal tube suction. Temporary device for emergen- ment of laryngeal tube and cuff inflation, thestic procedures? Anesth Analg 86:635–639 cy patients with a difficult airway. Anaesthesist 59:210–216 it is important to adjust and monitor the 6. Caplan RA, Benumof JL, Berry FA et al (2003) ASA task force on difficult airway management. Prac- 23. Timmermann A, Braun U, Panzer W et al (2007) cuff pressure. Problem-solving strategies tice guidelines for management of the difficult air- Out-of-hospital airway management in northern should be taught in seminars and train- way. Anesthesiology 98:1269–1277 Germany. Physician-specific knowledge, proce- dures and equipment. Anaesthesist 56:328–334 ing courses and further education must 7. Heidegger T, Gerig HJ, Henderson JJ (2005) Strat- egies and algorithms for the management of dif- 24. Gries A, Zink W, Bernhard M et al (2006) Realistic include employing the device in patients, ficult airway. Best Pract Res Clin Anaesthesiol assessment of the physician-staffed emergency perhaps in the OR [37]. Furthermore, and 19:661–674 services in Germany. Anaesthesist 55:1080–1086 25. Bernhard M, Mohr S, Weigand MA et al (2012) De- particularly in difficult airway situations, 8. Henderson JJ, Popat MT, Lotto IP, Pearce AC (2004) Difficult airway society guidelines for manage- veloping the skill of endotracheal intubation: im- capnography is mandatory [38]. Ulti- ment of the unanticipated difficult intubation. An- plication for emergency medicine. Acta Anaesthe- mately, the success of inserting the la- aesthesia 59:675–694 siol Scand 56:164–171 26. Reifferscheid F, Harding U, Dörges V et al (2010) ryngeal tube can only be as good as the 9. Schalk R, Meininger D, Ruesseler M et al (2011) Emergency airway management in trauma pa- Implementation of a specialist qualification in operator’s training. tients using laryngeal tube suction. Prehosp emergency medicine—do we now have uniform Emerg Care 15:347–350 requirements in Germany? Anästh Intensivmed 10. Gahan K, Studnek JR, Vandeventer S (2011) King 51:82–89 Corresponding address LT-D use by urban first respond- 27. Genzwürker H, Lessing O, Ellinger K et al (2007) In- ers as the primary airway device for out-of-hospi- frastructure of emergency medical services. Com- parison of physician-staffed ambulance equip- Dr. M. Bernhard tal cardiac arrest. Resuscitation 82:1525–1528 ment in the state of Baden-Wuerttemberg in 2001 Emergency Department, 11. Emerson GB, Warme WJ, Wolf FM et al (2010) Test- ing for the presence of positive-outcome bias in and 2005. Anaesthesist 56:665–672 University Hospital of Leipzig 28. Kikuchi T, Kamiya Y, Ohtsuka T et al (2008) Ran- Liebigstr. 20, 04103 Leipzig peer review. A randomized controlled trial. Arch Intern Med 170:1934–1939 domized prospective study comparing the laryn- Germany 12. Schalk R, Scheller B, Habler O et al (2008) Dispos- geal tube suction ii with the Proseal™ larynge- [email protected] able laryngeal tube suction—a randomized com- al mask airway in anesthetized and paralyzed pa- parison of two insertion techniques performed by tients. Anesthesiology 109:54–60 novice users in anaesthetised patients. Resuscita- 29. Rai MR, Popat MT (2011) Evaluation of airway Authors’ contributions. MB, WB, and AG collected tion 76:364–368 equipment: man or manikin. Anaesthesia 66:1–3 the cases. MB, WB, CAG, AT, and AG analyzed the per- 13. Keul W, Bernhard M, Völkl A et al (2004) Methods 30. Bernhard M, Matthes G, Kanz KG et al (2011) Emer- tinent complications and problems. MB, WB, and AG of airway management in the prehospital emer- gency anesthesia, airway management and venti- prepared the first version of the manuscript. UXK, RS, gency medicine. Anaesthesist 53:978–992 lation in . Background and key mes- AT, and CAG contributed intellectually to the writing 14. Kurola JO, Turunen MJ, Laakso JP et al (2005) A sages of the interdisciplinary S3 guidelines for ma- process and performed substantial corrections. All au- Comparison of the laryngeal tube and bag–valve jor trauma patients. Anaesthesist 60:1027–1040 thors participated in the writing process. All authors mask ventilation by emergency medical techni- 31. Gabrielli A, Wenzel V, Layon AJ et al (2005) Lower read and approved the final manuscript. cians: a feasibility study in anesthetized patients. esophageal sphincter pressure measurement dur- Anesth Analg 101:1477–1481 ing cardiac arrest in humans: potential implica- Acknowledgement. We would like to thank Dr. T.K. tions for ventilation of the unprotected airway. An- Becker (Department of Emergency Medicine, Universi- esthesiology 103:987–899 ty of Michigan) for his assistance in preparing the Eng- lish version of this manuscript.

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32. Gaither JB, Matheson J, Eberhardt A, Colwell CB Leipziger Interdisziplinäres Forum für Notaufnahme (2010) Tongue engorgement associated with pro- longed use of the king-LT laryngeal tube device. und Notfallmedizin 2014 (LIFMED) Ann Emerg Med 55:367–369 33. Khaja SF, Provenzano MJ, Chang KE (2010) Use of the king LT for emergency airway management. Arch Otolaryngol Head Neck Surg 136:979–982 34. Stillman PC (2003) Lingual oedema associated with the prolonged use of an inappropriately large (LMA™) in an infant. Paedi- atr Anaesth 13:637–639 35. Twigg S, Brown JM, Williams R (2000) Swelling and cyanosis of the tongue associated with use of

a laryngeal mask airway. Anaesth Intensive Care 28:449–450 36. Bernhard M, Helm M, Aul A, Gries A (2004) Preclini- cal management of multiple trauma. Anaesthesist 53:887–904 37. Schalk R, Auhuber T, Haller O et al (2012) Imple- mentation of the laryngeal tube for prehospital airway management. Training of 1,069 emergency physicians and paramedics. Anaesthesist 61:35–40 38. Timmermann A, Brockmann JC, Fitzka R, Nickel EA (2012) Measurement of carbon dioxide in emer- gency medicine. Anaesthesist 61:148–155 39. Timmermann A, Russo SG, Eich C et al (2007) The out-of-hospital esophageal and endobronchial in- tubations performed by emergency physicians. Vor dem Hintergrund des Erfolges des Fallberichte geben Beispiele aus der Praxis. Anesth Analg 104:619–623 Leipziger Interdisziplinärem Forums für Besonders hervorzuheben ist die Sitzung 40. Timmermann A, Byhahn C, Wenzel V et al (2012) Handlungsempfehlung für das präklinische Atem- Notaufnahme und Notfallmedizin (LIFEMED) „Erwartungen an die Zentrale Notaufnahme“ wegsmanagement. Für Notärzte und Rettungsas- 2013 wollen die Veranstalter auch in diesem mit Eingangsreferaten durch Vertretern des sistenten. Anästh Intensivmed 53:294–308 Jahr wieder diese interessante und praxis­ niedergelassenen Bereichs, der Notärzte, der 41. Frascone RJ, Russi C, Lick C et al (2011) Compari- son of prehospital insertion success rates and time relevante notfallmedizinische Veranstaltung Krankenhausleitung, der Fachabteilung, aber to insertion between standard endotracheal in- am 10.-12. Oktober 2014 am Universitäts­ auch des in der Notaufnahme eingesetzten tubation and a supraglottic airway. Resuscitation klinikum in Leipzig anbieten. Personals und anschließender Podiumsdis- 82:1529–1536 42. Russo SG, Cremer S, Galli T et al (2012) Random- LIFEMED richtet sich bundesweit an alle kussion. ized comparison of the i-gel™, the LMA Supreme™, notfallmedizinisch Aktiven im Bereich der Darüber hinaus wird das LIFEMED-Sym- and the laryngeal tube suction-D using clinical Präklinik und Klinik. Dem interdisziplinären posium durch Hands-on-Workshops zu and fiberoptic assessments in elective patients. BMC Anesthesiol 12:18 und interprofessionellen Ansatz bei der Ver- invasiven Notfalltechniken und Atemwegs­ 43. Müller JU, Semmel T, Stepan R et al (2013) The use sorgung von Notfallpatienten entsprechend, management, einem ­Deeskalationstraining if the laryngeal tube disposable by paramedics sind Mitarbeiterinnen und Mitarbeiter des sowie einem Update „Interdisziplinäre during out-of-hospital cardiac arrest: a prospec- tively observational study (2008–2012). Emerg Rettungs- und Notarztdienstes, nichtärztli- Notfallmedi­zin für Berufseinsteiger“ Med J 30:1012–1016 ches Personal und ärztliches Personal in der ergänzt. Das Come-Together am ersten 44. Sunde GA, Brattebo G, Odegarden T et al (2012) Notfallaufnahme, aber auch aus den weit- Veranstaltungs­abend wird Gelegenheit zum Laryngeal tube use in out-of-hospital cardiac ar- rest by paramedics in Norway. Scand J Trauma Re- erbehandelnden Bereichen gleichermaßen Erfahrungsaustausch und direktem Dialog susc Emerg Med 20:84 willkommen. mit den Referenten und Teilnehmern geben. 45. Kahja SF, Chang KE (2013) Airway algorithm for Das Vortragsprogramm greift dabei eine the management of patients with a king LT. Laryn- goscope 124:1123–1127 breite Vielfalt notfallmedizinischer Themen Informationen unter www.lifemed-zna2014.de 46. Schalk R, Weber CF, Byhahn C et al (2012) Reintu- der zentralen Notaufnahme wie Intoxika- bation using the C-MAC videolaryngoscope. Im- tionen, gastroenterologische und onkolo- Kontakt: plementation in patients with difficult airways ini- tially managed with in situ laryngeal tubes. Anaes- gische Notfälle, Trauma- und Management Prof. Dr. med. André Gries thesist 61:777–782 vital gefährdeter nicht traumatologischer Universitätsklinikum Leipzig AöR 47. Wang HE, Szydlo D, Stouffer JA et al (2012) Endo- Patienten aber auch aktuelle Fragen zur Liebigstrasse 20, 04103 Leipzig tracheal intubation versus supraglottic airway in- sertion in out-of-hospital cardiac arrest. Resuscita- Labor- und bildgebenden Notfalldiagnostik Tel.: 0341-9717080 tion 83:1061–1066 und zum Vorgehen bei Patienten mit multire- Fax.: 03419717969 48. http://www.aagbi.org/sites/default/files/prehospi- sistenten Keimen auf. Zahlreiche interaktive Email: [email protected] tal_glossy09.pdf. Accessed 02 June 2014

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