Supraglottic airway device placement by respiratory therapists

a b s t r a c t

Objective: Respiratory therapists (RTs) are some of the first staff to arrive at in-hospital incidents where cardio- pulmonary resuscitation (CPR) is needed, yet at some facilities, their ability to intubate is limited by hospital scope of practice. During the intubation process, CPR is often interrupted which could potentially increase the likelihood of adverse patient outcomes. Training RTs to secure the airway using non-intubation methods may re- duce or eliminate time for CPR interruptions and allow for earlier continuous/uninterrupted chest compressions. Design: A pilot study was developed to assess the effectiveness of a new policy for RT scope of practice.

Methods: RTs were trained for supraglottic airway device placement prior to procedure initiation. After each de- vice insertion event, RTs completed a written survey. Time between cardiac arrest and device insertion, number of insertion attempts, ease of placement, technical specifications of the device, complications, and survival were compiled and compared between supraglottic airway device and endotracheal tube placement.

Results: Procedural information from 23 patients who received a supraglottic airway device during the trial was compared to retrospective data of CPR events requiring intubation from the previous year. Time between initia- tion of cardiac arrest and advanced airway placement decreased significantly (p b 0.0001) when RTs placed the supraglottic airway device (4.7 min) versus ETT at CPR events the previous year (8.6 min). Device-associated complications were minimal and patient mortality was the same regardless of device.

Conclusion: We propose that more RTs should be trained to insert Supraglottic airway devices during inpatient CPR events.

Introduction

As the healthcare system in the United States continues to change, the responsibilities and duties assigned to physician assistants and other medical support staff will change as well [1]. Although respiratory therapists (RTs) are often the first members of the cardiac arrest team to arrive at cardiopulmonary resuscitation (CPR) events, they are not per- mitted to intubate patients at our institution because intubation re- quires more skill and training than our RTs receive due to hospital policy regarding the role of RTs in clinical practice. RTs either begin or take over manual ventilation via bag/valve/mask and wait for another team member trained for intubation with an Endotracheal tube to arrive at the scene. During the intubation process, CPR is generally stopped temporarily although chest compressions can sometimes con- tinue during this procedure. Taking into account other factors that im- pact CPR quality, Continuous chest compressions of sufficient depth, force, and frequency as well as the presence of minimal pulmonary ac- tivity (i.e., gasping) are associated with improved survival and favorable neurological outcomes [2-11]. Maximizing chest compression efficiency

* Corresponding author at: Marshfield Medical Center, 611 Saint Joseph’s Avenue, Marshfield, WI 54449, USA.

E-mail address: [email protected] (D.J. Heegeman).

and establishing a Secure airway immediately during CPR events may improve patient survival during in-patient CPR events [2-11]. Training RTs to secure an airway during CPR events in the hospital could poten- tially reduce or eliminate the need for CPR interruption and ensure a patent airway during resuscitation efforts. In this brief report, we de- scribe our training strategy and provide preliminary data to support a larger role for RTs during in-patient CPR events.

Airway support tools

Supraglottic airway devices are used in the prehospital and surgical settings to maintain a patient’s airway during rescue efforts and prevent airway occlusion during anesthesia, cardiac arrest, or resuscitation [12]. These devices are placed through the mouth to direct air into the tra- chea and prevent gastric aspiration by either blocking the esophagus or redirecting gastric outflow [12]. Since these devices are not meant to enter the trachea, minimal training is required for proper device placement [12]. A major benefit to supraglottic airway device placement though is a decrease in time for CPR interruption [13]. CPR interruptions of any duration reduce blood flow, and interruptions N10 s are associ- ated with decreased mean arterial pressure [4, 8, 10]. Since favorable Survival and neurological outcomes are dependent in part on efficient chest compressions and minimal pulmonary activity (i.e., gasping),

https://doi.org/10.1016/j.ajem.2018.06.030

1846 D.J. Heegeman et al. / American Journal of Emergency Medicine 36 (2018) 1845-1848

maximizing CPR and providing a secure airway for in-patients experiencing an event requiring CPR is necessary [2-11].

Although there are many supraglottic airway devices available for clinical use, the King Airway LTS-D(TM) device was selected for use during inpatient cardiac arrest events for several reasons. First, the single lumen design facilitates airway placement (i.e., no confusion regarding lumen use for ventilation) and is less likely to enter the trachea com- pared to double lumen devices like the Combitube [12]. Secondly, sim- ilar devices are used in out-of-hospital conditions and are preferred by Emergency medical service providers [12, 14]. Third, the King LTS-D(TM) Airway is more easily removed from the airway after successful resusci- tation compared to the Combitube [15]. This property is particularly useful for our purposes, as the airway device is only meant to secure the airway during a CPR event and will not be used for long-term airway support. Lastly, there is good skill retention of King Airway placement compared to ETT in paramedics familiar with bag/valve/mask ventila- tion who were trained to administer a supraglottic airway device and ETT [16].

Methods

Procedural implementation and training

This procedure was approved by the institutional review board as a quality improvement study.

About two months prior to procedural implementation, anesthesiol- ogists and physicians in the emergency department and various inten- sive care units were notified that RTs would be inserting a supraglottic airway device (King Airway LTS-D(TM); Ambu(R), Ballerup, Denmark) at in- patient CPR events requiring an artificial airway and chest compres- sions. Initially, physicians were apprehensive of the procedural change, as this was a new role for RTs. However, we assured them that the supraglottic airway device placement was temporary and would not take the place of ETT. If the patient survived resuscitation ef- forts and was transferred to an intensive care unit, he/she would still be intubated with an ETT per standard-of-care procedures.

Approximately one month prior to implementation, all RTs respon- sible for cardiac arrest response were trained to insert the device by watching a video on King LTS-D(TM) insertion [17]. Procedural compe- tency was confirmed by two successful insertions of the device in a manikin. Forty-four RTs were trained for supraglottic airway device placement.

During the implementation phase of this study, two supraglottic air- way devices sizes #4 and #5 were kept in the cardiac arrest kit in acute care departments. The #4 device was used for patients less than 5 ft tall, and the #5 device was used for patients over 5 ft. RTs were instructed to insert the device at inpatient CPR events in patients that did not have a pre-existing ETT in place. RTs were permitted to adjust cuff inflation to optimize airway patency. Patients with blocked airways or other contra- indications for supraglottic airway device placement received ETT intu- bation by other staff members. Patients with return of spontaneous circulation (ROSC) were later intubated after a period of stabilization in an intensive care room.

Evaluation

Patient outcomes and RT assessment of supraglottic airway device placement during CPR events were tracked by RTs using a two-part written survey after airway device placement. The RTs that placed the device recorded their name, date and time of patient CPR initiation, and time of supraglottic airway device placement. CPR event times ranging between 0701 and 1500 h were considered as occurring during the day shift, time ranges between 1501 and 2300 h were considered the evening shift, and time ranges between 2301 and 0700 h were con- sidered the night shift. A Likert scale of 1-5 was used to gauge ease of insertion with one being easy and five listed as difficult. RTs also

reported the number of device attempts and/or failure to place the de- vice as well as criteria used for evaluating successful device placement including bilateral chest sounds, equal chest rise, change in capnometer color, and an increase in oxygen saturation. Patient mortality and/or ROSC as well as whether the patient received ETT intubation was also recorded. Information collected regarding ETT intubation included the name of the anesthesiologist/anesthetist exchanging the devices, date and time of airway change, and type of exchange from the supraglottic airway device to an ETT specifically a tube exchanger (Bougie), fiber optic bronchoscopy, or direct laryngoscopy intubation. In some cases of ROSC, the airway device was removed when the patient regained consciousness, began breathing, and/or started gagging on the device. Technical specifications such as cuff inflation and volume were also re- ported as were any complications including air leakage around the cuff, vomiting, and tube malposition in addition to more serious complica- tions such as bleeding.

To evaluate the effectiveness of the new procedure to reduce time during inpatient cardiac arrests and improve patient outcomes, the RT-reported data was compared with a convenience sample of 23 CPR event cases requiring artificial airway placement (ETT) in 2014. The data abstracted from these cases included time between CPR initiation and airway placement, ROSC, and patient survival. The overall differ- ence in time to secure a patent airway during inpatient cardiac arrest events was compared using a one-tailed Mann-Whitney U test at a sig- nificance threshold of 0.05 (GraphPad Prism ver. 7).

Results

Over the 16-month study period from January 2015 until April 2016, 31 inpatients received supraglottic airway device placement from 18 different RTs though only 23 cases were included for analysis. Cases were excluded if a healthcare provider other than the RT placed the de- vice, supraglottic airway device insertion was contraindicated, or the device was successfully placed for a compromised airway, but the pa- tient was not experiencing cardiac arrest. One case lacked complete documentation and was also not included.

The mean time from CPR initiation until intubation pre-RT training was 8 min and 36 s (range: 2-19 min). During implementation of supraglottic airway device placement by RTs, the mean time from

Fig. 1. Box-and-Whisker Plot of the Time to Establish Secure Airway Utilizing the King LTS- D Airway and ETT Intubation Techniques. The asterisk denotes a statistically significant difference between groups (p-value b 0.05).

D.J. Heegeman et al. / American Journal of Emergency Medicine 36 (2018) 1845-1848 1847

Table 1

RT survey responses.

Survey characteristics Responses

number of attempts Mean: 1.2 attempts

Range: 1-3 attempts

Success rate

First attempt 83% (19/23)

Second attempt 13% (3/23)

Ease of insertion Mean: 1.5 (1-4)

Verification of successful placement

Bilateral lung sounds 91% (21/23)

Equal chest rise 91% (21/23)

Change in capnometer color 91% (21/23)

Increased oxygen saturation 39% (9/23)

Cuff inflation volume Range: 50-120 mL

time of insertion

Day 17% (4/23)

Evening 35% (8/23)

Night 48% (11/23)

Complications

Air leakage 9% (2/23)

Cuff rupture 4% (1/23)

Tube malposition 4% (1/23)

Vomiting 9% (2/23)

Patient mortality 6

initiation of cardiac arrest until airway device placement decreased to 4 min and 42 s (range: 1-15 min), and there was no interruption of CPR. There was a significant decrease in time for airway establishment between intubation and supraglottic airway device (one-tailed U test: 95, sum of ranks: 710, 371, n₁ = n₂ = 23, p b 0.0001) and no significant difference in patient mortality (Fig. 1). Twelve patients had a successful tube exchange, and three had their devices removed due to gagging and a return to spontaneous breathing.

RTs were usually able to successfully insert the supraglottic airway device on the first attempt (maximum number of tries reported: three) and considered device insertion as easy (Table 1). Most RTs doc- umented successful placement as bilateral lung sounds, equal chest rise, Declaration of interest“>and change in capnometer color. Of the 23 supraglottic airway device placements, 17% occurred during the day shift, 35% on the evening shift, and 48% on the night shift.

Overall, RTs correctly used the supraglottic airway device to secure the patient’s airway during a CPR event. In two cases not fitting inclu- sion criteria, RTs attempted to use the device for patients where the air- way was blocked, either by vomitus or a large nasogastric tube and blood. In another case, a supraglottic airway device was used to support a compromised airway but the patient was not experiencing cardiac ar- rest. No complications were associated with supraglottic airway device insertion during the day shift. However, there were two reports of air leakage until the cuff was properly inflated during the evening shift, one instance of cuff rupture, and one tube malposition that was resolved with repositioning during the night shift. The patient that received the ruptured cuff was intubated and the device sent back to the manufac- turer for analysis. One RT commented that it was difficult to open the package, but most RTs listed no complications (17/23) associated with supraglottic airway device placement. No serious complications associ- ated with supraglottic airway device insertion were reported during the study period.

Discussion

Performing successful manual ventilation via bag/valve/mask re- quires a high level of expertise. Very often it is difficult to ensure that the patient is being properly oxygenated and ventilated because chest compressions, shifts in head tilt/Chin lift, oropharyngeal blockage, and poor lung compliance can interfere with delivery of manual breaths. Over-ventilating patients using bag/valve/mask or any advanced airway device is not recommended by current Advanced Cardiovascular Life

Support guidelines, as this may restrict venous return [10, 19]. Permit- ting RTs to place a supraglottic airway device immediately at inpatient CPR events versus providing bag/valve/mask airway maintenance or waiting for other staff to intubate may increase the speed of securing an airway compared to direct intubation, shorten the duration of 30:2 CPR, permit uninterrupted chest compressions, and prevent overventilation.

With training, RTs are able to successfully place a supraglottic airway device easily, effectively, and safely in a much shorter time than waiting for ETT intubation by other team members. Complications associated with supraglottic airway device placement are minimal and not unlike those encountered during ETT. Since RTs were able to adjust cuff infla- tion for each patient, adverse displacement/compression of neck vascu- lature during resuscitation attempts is presumably minimal [20]. Duration of supraglottic airway device use prior to intubation also did not produce any evident complications, and mortality did not change compared to a similar number of in-hospital cardiac arrest events with ETT.

Although our study is underpowered to detect significant changes in patient outcomes aside from overall survival, this study provides pre- liminary support for increased RT training to secure patient airways using a supraglottic airway device during CPR events. RTs were able to successfully administer a supraglottic airway device regardless of shift (i.e., during the evening or night shifts when the hospital has fewer and/or less-experienced staff on hand to respond to a CPR event), which indicates that skill retention of RTs placing these devices is high. Training RTs to insert a supraglottic airway device during an inpa- tient CPR event would decrease time for establishing a secure airway and permit uninterrupted CPR as other team members arrive. We pro- pose that hospital policies regarding RT training should be modified to permit RTs to place supraglottic airway devices during CPR events.

Funding sources

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Declaration of interest

None.

Presentation

This work was presented as a poster and presentation at the Interna- tional Respiratory Congress of the American Association for Respiratory Care (AARC) on October 17, 2016 in San Antonio, Texas.

Acknowledgements

The authors would like to acknowledge Emily Andreae, PhD, for manuscript assistance.

References

AJEM