Study Compares Airway Techniques for Pediatric Patients

Should providers intubate or use the King LT-D?

 

 
 
 

Keith Wesley, MD, FACEP | Marshall J. Washick, BAS, NREMT-P | | Tuesday, August 9, 2011


Review Of: Ritter SC, Guyette FX. Prehospital Pediatric King LT-D use: A pilot study. Prehosp Emerg Care. 2011;15(3):401–404.

The Science
This is a small pilot study on the use of the King LT-D in a pediatric mannequin. Forty-five flight paramedics and flight nurses were recruited to participate. All participants were given an 11-question survey to complete based on a 1–5 Likert scale: 1 being “strongly disagree,” and 5 being “strongly agree.” Training was limited because the participants had been using the adult version for at least three years. The authors found that overall participants rated the King LT-D as easier to use than endotracheal intubation (ETI) and would recommend it as an alternative airway, instead of replacing the primary means of securing an airway ETI.

Dr. Wesley: I love studies like this. They’re totally ripe for criticism. I know that you readers feel like the tide is against you when it comes to prehospital intubation, and studies like this only add to the height of the tsunami. But as they say, the devil is in the details, and that is where this study gets interesting.

First, this is a mannequin study. The outcomes were based on successful placement and time to insertion. How this would relate to real-world experience is unknown. Also, the study participants were air medical paramedics and flight nurses. One has to expect that they have significantly greater experience in airway management, but also that they have significantly different views on the role of rapid sequence intubation (RSI) and intubation.

This brings me to the second issue. In the paper, the participants rate the procedure on array of areas such as ease, training, etc. They agree overall that this device is just as effective as the ET tube, but when asked if they would consider this as the primary means of establishing an airway in the pediatric patient they answer “no.” Why? The authors didn’t ask. I think this is important. What’s the point of training them to use it if they won’t use it in real life?

I support the use of the pediatric King LT-D for many reasons—some of which I’ve discussed in previous articles. It’s faster, easier, and just as effective as the ET tube. And with the extremely low incidence of pediatric airway management, it’s impossible to maintain proficiency with training.
But to be successfully implemented, it requires real-world experience and a strong emphasis on its usefulness to providers.

Medic Marshall: Although the Doc feels this study is “ripe for criticism,” I’m going to disagree with him. I think it’s important to note this is a pilot study, meaning the authors may be preparing for a similar study to perform on live patients–but they need to demonstrate ease, success and the ability to perform the skill. Does this add to the “tsunami” of studies aimed at making pre-hospital ETI irrelevant? I don’t think so. It’s a small, novel study based on one services’ flight paramedics and flight nurses. But the one thing I also found disturbing was this:

“The subjects agreed that the pediatric King LT-D was easier to place than a pediatric endotracheal tube; they strongly agreed that they would use the pediatric King LT-D as an alternative airway. The participants disagreed that they would prefer the pediatric King LT-D as a primary means of securing pediatric airways.”

Does anyone else see the problem here? The participants rated it easier to use the King LT-D versus ETI, yet would not use it a primary means for securing an airway? I’d like to know exactly why as well.

When you examine Figure 1 in the study, it uses a Whisker and Box plot to help visualize the responses. Although the responses range from 1 “strongly disagree” to 5 “strongly agree,” the majority of responses seem to fall on the positive end of the spectrum. So for me, I can’t understand why the participants wouldn’t want to use this as a primary means of securing an airway, especially when growing evidence exists that delays in securing an airway is detrimental to patient outcomes.

Pediatric patients pose unique challenges for EMS providers, and even though providers may have a high rate of exposure and success for using ETI on adult patients, this may not directly translate into success for pediatric patients. If anything can make the care we provide to our patients faster and easier, then I’m all for it.


Abstract

Objective: To determine whether prehospital providers can successfully place a pediatric King laryngeal tube (LT-D) and ventilate a Laerdal SimBaby pediatric simulator during a respiratory arrest simulation.

Methods: We studied the ability of 45 paramedics and flight nurses to place the pediatric King LT-D in a SimBaby manikin. For the purposes of this study, paramedics and flight nurses were considered equivalent, because in this air medical system they have the same scope of practice in regard to airway skills. Because the participants had previous training and field experience with the adult King LT-D, we limited pediatric King LT-D training to our standard adult training plus selecting the correct size and inflation volumes for the device. Outcomes included rate of successful pediatric King LT-D placement, number of attempts to correctly place the tube, and time to first adequate ventilation. The subjects were evaluated on airway management using an 11-point skill test. A score of 8 or greater (≥73%) was considered passing. The subjects indicated their perceptions and preferences for the pediatric King LT-D using a five point Likert scale. Data were analyzed using descriptive statistics.

Results: Crew members successfully placed the pediatric King LT-D 95.5% (43/45) of the time. The median number of attempts was one. Four
subjects required a second attempt; two of these subjects failed at placement. Mean time to placement was 34 seconds (95% confidence interval [CI]: 26.4–67.3 sec). Ninety percent of the participants (40/45) successfully completed the skill test, with a mean score of 78.2% (95% CI: 73.6–82.7). The subjects strongly agreed that their previous training on the November 27, 2010, from the University of Pittsburgh School of Medicine (SCR), Pittsburgh, Pennsylvania; the Department of Emergency Medicine (FXG), University of Pittsburgh, Pittsburgh, Pennsylvania; and STAT MedEvac (FXG), West Mifflin, Pennsylvania. Revision received November 11, 2010; accepted for publication November 11, 2010.

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Address correspondence and reprint requests to: Francis X. Guyette, MD, MPH, 3600 Forbes Avenue, Iroquois Building, Suite 400A, Pittsburgh, PA 15213. e-mail: guyettef@upmc.edu doi: 10.3109/10903127.2011.561400 adult King LT-D and using it in the field had adequately prepared them to use the pediatric King LT-D. The subjects agreed that the pediatric King LT-D was easier to place than a pediatric endotracheal tube; they strongly agreed that they would use the pediatric King LT-D as an alternative airway. The participants disagreed that they would prefer the pediatric King LT-D as a primary means of securing pediatric airways.

Conclusions: The pediatric King LT-D was quickly and reliably placed. Providers perceived the pediatric King LT-D to be easier to use than pediatric endotracheal intubation in this setting. Keywords: pediatrics; laryngeal tube; alternative airway; supraglottic airway; emergency medical
services; prehospital; King LT-D. Prehosp Emerg Care. 2011;15:401–404.


 




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Related Topics: Patient Care, Airway and Respiratory, Street Science, RSI, pediatrics, Marshall Washick, King LT-airway, Keith Wesley, intubation, ETI

 
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Keith Wesley, MD, FACEP

Keith Wesley, MD, FACEP, is the Minnesota State EMS medical director and the EMS medical director for HealthEast Ambulance in St. Paul, Minn. and and can be reached at drwesley@emsconsulting.net.

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Marshall J. Washick, BAS, NREMT-Pis a paramedic and the peer-review/research coordinator for HealthEast Medical Transportation. He can be contacted at MjWashick@HealthEast.org.

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