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American Journal of Emergency Medicine 32 (2014) 14451449

Contents lists available at ScienceDirect

American Journal of Emergency Medicine


journal homepage: www.elsevier.com/locate/ajem

Original Contribution

Airway control in case of a mass toxicological event: superiority of


second-generation supraglottic airway devices
Nimrod Ophir, MD a, Erez Ramaty, MD a, Inbal Rajuan-Galor, MD, MPH a, Yossi Rosman, MD a,,
Ophir Lavon, MD a, Shai Shrot, MD a, Arthur Shiyovich, MD a, Michael Huerta-Hartal, MD, MPH a,b,
Michael Kassirer, MD a,b, Sonia Vaida, MD c, Luis Gaitini, MD c
a
b
c

Israel Defense Forces, Medical Corps, Tel Hashomer, Israel


Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
Anesthesiology Department, Bnai Zion Medical Center, Faculty of Medicine, Technion Institute of Technology, Haifa, Israel

a r t i c l e

i n f o

Article history:
Received 31 July 2014
Received in revised form 22 August 2014
Accepted 23 August 2014

a b s t r a c t
Introduction: Early respiratory support and airway (AW) control with endotracheal intubation (ETI) are crucial in
mass toxicology events and must be performed while wearing chemical personal protective equipment (C-PPE).
Aim: The aim of this study is to evaluate the efciency of AW control by using second-generation supraglottic AW
devices (SADs) as compared with ETI and rst-generation SAD while wearing C-PPE.
Methods: This is a randomized crossover trial involving 117 medical practitioners. Four AW management devices
were examined: endotracheal tube, the rst-generation SAD, laryngeal mask AW unique and 2 secondgeneration SAD, the laryngeal tube suction disposable, and supreme laryngeal mask AW (SLMA). Primary end
point measured were success or failure, number of attempts, and time needed to achieve successful device insertion. Secondary end point was a subjective appraisal of the AW devices by study population.
Results: More attempts were required to achieve AW control with endotracheal tube, with and without C-PPE
(P b .001). Time to achieve AW control with ETI was, on average, 88% longer than required with other devices
and improved with practice. The mean times to achieve an AW were longer when operators were equipped
with C-PPE as compared with standard clothing. Subjectively, difculty levels were signicantly higher for ETI
than for all other devices (P b .0001).
Conclusions: When compared with ETI, the use of SADs signicantly shortened the time for AW control while
wearing C-PPE. Second-generation SAD were superior to laryngeal mask AW unique. These nding suggest
that SADs may be used in a mass toxicology event as a bridge, until denite AW control is achieved.
2014 Elsevier Inc. All rights reserved.

1. Introduction
Recent events in the Middle East have refocused attention on the potential threat of using chemical warfare agents in cases of military conict as well as against civilian population [1].
The leading cause of mortality in many cases of mass intoxication is
acute respiratory failure. Most chemical warfare agents as well as other
toxic industrial compounds result in respiratory distress and failure by
assortment of mechanism, including bronchospasm, bronchial secretions, and alveolar loss. Other mechanism involve depression of the
ventilatory drive and respiratory muscles paralysis such as in case of
organophosphates (OPs) nerve intoxication [2-4]. The latter are particularly lethal because of their extremely high toxicity [5].
Chemical personal protective equipment (C-PPE) is crucial to prevent
secondary contamination of the caregivers, before the victims undergo

Supporting sources: None.


Corresponding author. Israel Defense Forces, Medical Corps. Tel.: +927 52 925 6113.
E-mail address: rosmanyossi@gmail.com (Y. Rosman).
http://dx.doi.org/10.1016/j.ajem.2014.08.067
0735-6757/ 2014 Elsevier Inc. All rights reserved.

complete decontamination [6]. Early airway (AW) management is a key


clinical intervention and includes not only AW control, assisting ventilation, and oxygen supplementation but also stomach drainage by gastric
tube to avoid aspirations of excessive secretions [7].
The criterion standard regarding denitive AW control is endotracheal intubation (ETI) [8]. Successful ETI requires skill, time and assistance and depends greatly on the experience of the caregiver [9].
Previous studies have shown that even minimal protection gear causes
difculty in AW management efforts while performing ETI [10] and that
full protection gear prolongs the time to ETI even among very skilled
personnel [11,12]. This is probably due to adverse effects on vision, tactile abilities, and general performance [13-18].
Supraglottic AW devices (SADs) are placed above the level of the vocal
cords and are designed to overcome the disadvantages of ETI. Although
they do not provide denitive AW control, these devices are faster and
easier to maneuver even by inexperienced medical personnel [19-22].
Second-generation SADs present additional advantages such as improved
pharyngeal seal, controlled ventilations at higher AW pressures, increased
esophageal seal mechanism, and a built-in gastric channel, which enables
gastric drainage, thereby reducing the risk of aspiration [23,24].

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N. Ophir et al. / American Journal of Emergency Medicine 32 (2014) 14451449

Fig. 1. Size, 7.0 mm ETT (A), LMAU (B), LTS-D (C), and SLMA (D).

The aim of this study was to evaluate the performance of medical


personnel in successful AW control comparing ETI, rst-generation,
and second-generation SADs, with and without C-PPE.
2. Methods
This was a randomized crossover trial, conducted in the Israeli Military Medical Academy. The study involved 5 groups of practitioners:
military medics, military paramedics, military general practitioners
(GPs), residents from varying specialties, and board-certied anesthesiologists. All practitioners were recruited through a convenience sample.
All participants provided data on their medical specialty, age, experience level (by years of practice experience). In addition, all participants were asked to subjectively evaluate their ability to perform
successful intubation (1, impossible; 10, very easy).
Four devices were used: endotracheal tube (ETT) size 8 (Portex; Smith
Medical, Asford, Kenet, UK) with direct laryngoscopy, the rst-generation
SAD laryngeal mask AW unique (LMAU) (Intravent Orthox, Maidenhead, UK) and 2 different second-generation SADs: the laryngeal tube suction disposable (LTS-D) (VBM Medizintechnik. GmbH, Sulz, Germany)
and the supreme laryngeal mask AW (SLMA) (Intravent Orthox) (Fig. 1).
All participants attended an AW workshop before the beginning of the
trial to optimize familiarity with the different devices. After that, each subject practiced each of the 4 study devices on an AW management trainer
(AW managment trainer; Laerdal, Stavanger, Norway) in a randomized
order: 3 procedures while wearing C-PPE and 3 while wearing standard

clothing. Each AW control procedure included up to 3 device insertion attempts. Procedure failure was dened as 3 sequential unsuccessful attempts. Correct device insertion was determined by visualization of lung
expansion of the AW managment trainer using bag valve ventilation.
Each participant inserted a lubricated gastric tube size 16 through
the gastric channel of the SLMA and LTS-D and through the nostril of
the simulator with the ETT. A gastric tube was not used in conjunction
with the LMAU, as this is not possible with this device.
In addition, all participants were asked to evaluate their perceived difculty of insertion for each device (1, extremely challenging; 10, very easy).
Primary end point measures included success or failure to achieve
AW control, number of attempts to achieve AW, and time to achieve
successful intubation. A secondary end point was subjective assessments of each AW device and gastric tube insertion.
2.1. Statistical analysis
Dichotomous measures for AW control were compared across device categories using 2 tests. Comparisons of mean number of attempts to successful AW control, mean time to AW control, and selfreported difculty levels were performed using Student t test and
were calculated for both the overall study population and for
category-specic strata. Operator performance measures for each SAD
were compared primarily to the respective value for ETI and secondarily, for mean time to AW control, to each other. A subset analysis of
mean time to successful AW was conducted, limiting the observations

Table 1
Participant age, experience, and self-reported skill level, by medical specialty

Overall
By medical specialty
Medics
Paramedics
GPs
Residentsa
Anesthesiologistsa
a

n (%)

Age (mean SD)

Experience level (y)

Self-reported skill level (mean SD)

b1

1-3

N3

117 (100)

24.7 7.2

80 (68.4)

12 (10.3)

24 (20.5)

6.8 1.8

26 (22.2)
27 (23.1)
24 (20.5)
20 (17.1)
20 (17.1)

19.4 1.1
19.4 1.0
26.7 1.3
35.2 5.2

25 (21.3)
27 (23.1)
21 (17.9)
6 (5.1)
1 (0.9)

1 (0.9)
0 (0.0)
3 (2.6)
8 (6.8)
0 (0.0)

0 (0.0)
0 (0.0)
0 (0.0)
5 (4.3)
19 (16.2)

7.4 1.7
7.2 0.9
6.0 1.3
6.1 2.6

Data on experience level are missing for 1 resident. Age and self-reported skill level were not recorded for anesthesiologists.

N. Ophir et al. / American Journal of Emergency Medicine 32 (2014) 14451449


Table 2
Mean number of attempts to successful AW control, by subject occupation and device type

Table 4
Results (P values) of comparisons of mean times with AW control, by device type

Device type

Overall
Occupation

Medic
Paramedic
GP
Resident
Anesthesiologist

ETT

LMAU

LTS-D

SLMA

1.11
1.23
1.15
1.01
1.13
1.00

1.00
1.01
1.00

1.01
1.00
1.00

1.01
1.01
1.01

1.00
1.00
1.00

1.00
1.05
1.01

1.02
1.03
1.00

P values are for t test comparison with ETT group.


P .05.

to those of operator using C-PPE. Statistical analyses were conducted


using IBM SPSS Statistics (version 21; SPPS, Chicago, IL) and WinPepi
(version 11.25) [25].
Statistical signicance was set at P b .05.
3. Results
One hundred seventeen subjects participated in the study, yielding a
grand total of 2808 potentially measurable procedures. Data were
recorded for 2723 (97%) of these procedures. Participant characteristics
are presented in Table 1. The various medical specialties were evenly represented. Study population was unevenly distributed over the spectrum of
experience level as a result of medics and paramedics' younger age and
lesser experience. Military medics and paramedics self-reported higher
subjective skill levels than did physicians. Although data on self-reported
skill level were not systematically collected from anesthesiologists, anecdotal reports from those who did provide this information placed their
subjective skill level at the highest possible score (10 0, data not shown).
We rst considered a dichotomous variable (success or failure of
AW management). This variable provided very little contrast in results;
of 2723 procedures, only 9 resulted in failure, all of them in the ETI
group (data not shown), yielding a total of 2714 successful procedures.
The mean number of attempts required to achieve AW control is
presented in Table 2. Overall, more attempts were required for the
ETT than for all other devices (P b .001). This nding remained consistent for all devices among military medics and paramedics and for the
LMAU and the SLMA among residents. No signicant differences
between the devices were detected among GPs and anesthesiologists.
The time required to achieve effective AW is presented in Table 3.
Overall, time to AW control with ETT was 88% longer than required
for the other devices. The time needed to achieve effective AW control
with an ETT was signicantly longer for all groups of participants and
for all skill and experience levels (P value for all comparisons,
b .0001). Even among anesthesiologists, a signicantly shorter time
was required to achieve effective AW management when using SADs
as compared with an ETT. Within the occupational strata, the shortest
Table 3
Mean time (seconds) to successful AW control, by subject characteristic and device type
Device type

Overall
Occupation

Experience

Skill

Medic
Paramedic
GP
Resident
Anesthesiologist
b1 y
1-3 y
N3 y
1-6
7-10

ETT

LMAU

LTS-D

SLMA

31.7
39.6
27.0
32.8
31.9
26.1
33.0
31.5
27.5
34.0
31.9

17.2
21.8
15.5
18.4
16.0
13.1
18.5
16.5
13.7
18.9
17.5

18.1
21.0
16.3
20.3
18.8
13.1
19.4
17.9
14.2
20.4
18.5

17.7
19.6
15.7
19.0
20.1
13.7
18.4
18.7
14.8
19.7
17.9

P values are for t test comparison with ETT group.


P .0001 for all comparisons.

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ETT
LMAU
LTS-D
SLMA

ETT

LMAU

LTS-D

SLMA

0.00

0.00
0.21

0.00
0.51
0.40

times were consistently recorded among anesthesiologists, followed by


military paramedics, residents, GPs, and military medics, for all devices
except the SLMA. Within the experience strata, there was a monotonic
decrease in time with increasing experience levels for all devices except
the SLMA device. Participants who reported higher skill levels needed
slightly shorter mean times to achieve effective AW management than
those with lower skill levels.
When comparing mean times between all devices, no signicant difference was noted among the different SADs (Table 4).
Next, we examined the effect of C-PPE on the mean times to AW
control (Table 5). Mean times to AW control with ETT were longer compared with the other devices both with and without the use of C-PPE
(P value for all comparisons, b .0001).
While using the same device, mean times were longer when participants were equipped with C-PPE. This difference was statistically
signicant for all devices (P b .001) but most pronounced for the ETT
(mean difference, 5.89 seconds or a 20.4% increase compared with no
protective gear).
We conducted a subanalysis limited to procedures done with CPPE (Table 6). Overall, AW control with the ETT was, on average,
91% longer than the time required for the other devices. This difference remained signicant for all occupations and for all skill and
experience levels (P value for all comparisons, b .01). Within the
occupational strata, mean times were consistently longest for military medics with all devices except for the SLMA and were consistently the shortest for anesthesiologists with all devices but ETT.
The most pronounced effect of shortening time to AW control
using SADs was within the anesthesiologists group (average decrease of 52%). Within the experience strata, there was a monotonic
decrease in time for increasing experience levels for all devices but
the SLMA. Participants who reported higher skill levels demonstrated slightly shorter mean times than those with lower skill levels.
The learning curves for all devices while wearing C-PPE are presented in Fig. 2. There was a notable decrease in time to AW control
using the ETT with increased practice. This improvement was most pronounced for medics and was least pronounced for military paramedics
and anesthesiologists.
Results of subjective difculty to achieve AW control are shown in
Fig. 3. Difculty levels were signicantly higher for the ETT device
than for all other devices (P for all comparisons, b .0001).
4. Discussion
This study demonstrates that second-generation SADs enable the fully
protected caregiver to achieve AW control faster than with ETI. The results
are in accordance with previous studies, which demonstrated that wearing C-PPE signicantly prolongs the time to AW control while using ETI
Table 5
Mean time (seconds) to successful AW control with and without C-PPE, by device type
Device type (mean time, in s)
C-PPE

ETT

LMAU

LTS-D

SLMA

Without
With
P

28.8
34.7
b.0001

15.6
18.9
.001

16.8
19.5
b.0001

16.8
18.6
.001

P values are for t test comparison with ETT group, P b .0001 for all comparisons.

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N. Ophir et al. / American Journal of Emergency Medicine 32 (2014) 14451449

Table 6
Mean time (seconds) to successful AW control using PPE, by subject characteristic and
device type
Device type (mean time, in s [P])

Overall
Occupation

Experience

Skill

Medic
Paramedic
GP
Resident
Anesthesiologist
b1 y
1-3 y
N3 y
1-6
7-10

ETT

LMAU

LTS-D

SLMA

34.7
42.0
29.6
34.8
36.1
30.4
35.5
34.1
32.5
36.9
34.7

19.0
24.2
16.8
21.3
16.2
14.3
20.7
17.3
14.8
20.6
19.9

19.5
23.9
16.6
21.8
19.3
14.3
21.0
18.2
15.6
21.9
20.1

18.6
20.7
16.2
19.5
20.9
15.1
19.0
20.4
16.3
20.5
18.7

P values are for t test comparison with ETT group.


P b .01 for all comparisons.

[11,12], SAD [26-28], and ETI aids [29]. However, most of these studies
were done on a small samples [11,12,26], were limited to anesthesiologists or paramedics [11,12,25,28,29], or did not compare ETI with SADs
[12,26-28]. None of these studies compared second-generation SADs
with ETI and rst-generation SADs in these groups of medical caregivers.
When comparing ETI with SAD insertions, SADs (both rst and second
generation) required less attempts to achieve AW control, with and without C-PPE. Moreover, mean times to successful AW control using the
same device were signicantly longer when participants were equipped
with C-PPE for all devices. This was most pronounced for the ETI with
an approximately 20% increase in time for AW control. We believe that
this difference could be explained by loss of ne motor abilities and dexterity due to C-PPE. Prolongation of the time needed to achieve AW control might inuence morbidity and mortality, especially when dealing
with a large number of casualties.
Second-generation SADs have few advantages over rst-generation
SADs. The main advantage of using is in its ability to achieve both ventilation and gastric content suctioning. Another advantage of the

All occupations

GPs

50

50

40

40

30

30

20

20

10

10
0

0
R1

R2

R3

R1

Medics

Residents

50

50

40

40

30

30

20

20

10

10

R2

R3

R2

R3

R2

R3

0
R1

R2

R3

R1

Paramedics

Anesthesiologists

50

50

40

40

30

30

20

20

10

10

0
R1

R2

R3

R1

Fig. 2. Mean time (seconds) to AW control over repeated practice maneuvers (R1-R3) using personal protective equipment, by occupation and device type.

N. Ophir et al. / American Journal of Emergency Medicine 32 (2014) 14451449

10

*
6

*
*

0
ETT

LMAU

LTS-D

SLMA

Fig. 3. Self-reported difculty in AW control.

second-generation SADs is that higher inspiratory peak pressure can be


used during positive pressure ventilation due to their improved seal.
First-generation SADs are less appropriate to high inspiratory pressure
and may result in air leak, inadequate ventilation, and gastric distention.
These advantages are especially benecial in situation of mass toxicology events (MTEs) with OPs or carbamets, where severe secretions may
dominate the clinical picture, and there is high risk of aspiration. In such
a hypersecretory state with low lung compliance, the possibility of high
seal pressure and insertion of gastric tube are very important features.
The decision to implement SADs in the management of MTE is
debateful because many toxic industrial compounds as well as OPs
have direct toxic effect on the lung tissue [30-32], resulting in a clinical
picture resembling acute lung injury and mandating denite AW
control. Nevertheless, we believe that SADs, especially of the second
generation, could be used for primary AW control and a bridge to
ETI after decontamination. The advantage of SADs about time for AW
control [11,16,33,34] is known. This is particularly important in MTE,
where prompt AW control may be needed for a large number of
causalities [6]. Our results demonstrate that this is applicable not only
to anesthesiologists or paramedics but also to GPs, and it is independent
of the experience level. In addition, we demonstrate that even
minimally qualied caregivers, who are not trained for SADs insertion,
can handle these devices quiet efciently while donning C-PPE. This
nding may be critical in cases of MTE, where the lack of experienced
caregiver might necessitate minimally qualied caregivers to use such
devices for AW control.
The main limitation of this study is the usage of mannequin model.
As expected, extremely high success rate was achieved because the
mannequin AW anatomy is very easily learned and assembled for
intubation success. We overcame these limitation by the study
randomized crossover design. Furthemore, we believe that our large cohort and the statistical analysis results exceed these limitations.
In conclusion, we demonstrated that using SADs signicantly
shortens the time to AW control while wearing C-PPE compared with
ETI. These ndings were noticed in all professions, including GPs, military medics, paramedics, and medical residents. Unless other solutions
to personal protection or AW management are available, secondgeneration SADs may be an important additive to the AW management
toolbox. This may be especially critical in cases of MTE, preferably as a
bridge, until denite AW is achievable.
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