Cite this post as:
Scott Weingart, MD FCCM. Are Extraglottic Airways Harmful in Cardiac Arrest?. EMCrit Blog. Published on June 17, 2012. Accessed on March 20th 2025. Available at [https://emcrit.org/emcrit/extraglottic-airways-harmful-cardiac-arrest/ ].
Financial Disclosures:
The course director, Dr. Scott D. Weingart MD FCCM, reports no relevant financial relationships with ineligible companies. This episode’s speaker(s) report no relevant financial relationships with ineligible companies unless listed above.
CME Review
Original Release: June 17, 2012
Date of Most Recent Review: Jul 1, 2024
Termination Date: Jul 1, 2027
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awesome wee! Thankyou. no where else would you get such cutting edge international resuscitation opinion.
Great interview! Interesting paper. Makes you think. What I’m going to do is continue using igel. Not sure about the seal, but It kind of makes sense. It doesn’t have a balloon, and I can put it in much quicker. It is a question of balance.
I think with no proof whatsoever, that the Igel is probably safe as I think the seal would be at minimum pressure. Dan Cook is also a developing an LMA that deflates during exhalation.
One question for whomever… Which type of LMA device were they using for the EGA study in regards to CBF? My service is currently trailing the LMA Supreme and Fastrach against the King LTSD. I did notice that it dose take more air to inflate the LMS Supreme over the LMS Fastrach due to balloon sizes. Our trial has ended and I am about to write a pros and cons comparison regarding the devices mentioned above. So this can possibly influence final decisions.
Thanks,
Matt King FP-C
they used these devices: King LTS-D, LMA Flexible, Combitube 41 F
Dr. Weingart,
I saw this presented at NAEMSP. What was most convincing about this article was that the next speaker was Dr. Henry Wang, who presented his paper from the ROC data comparing ETT vs SGA and survival. ETT wins by a long shot. Coincidence, I think not.
I don’t know the answer to this one, but on the reanalysis to the ROC data paper: this was a observational trial for airway choice. The medics chose SGA for a reason as opposed to intubating them. Despite multi-variate analysis, I don’t think this paper really answers the question.
Quite a few of these observational studies seem to show no airway intervention>ETI>SGA. I think this is most likely due to the nature of EMS responding to a cardiac arrest. The ‘one shock into rhythm’ patients won’t receive any advanced airway interventions and will obviously do better, but not because someone explicitly chose not to stick a tube down their throat. Likewise, most paramedics will attempt ETI first, only progressing to SGA as a ‘rescue device’ or if they predict a difficult intubation. This means that SGAs will be reserved for those patients who have had a longer down time,… Read more »
Chris–v. possible these are the reasons. We need a true RCT of apneic ox to ETT to SGA to really answer this ?. Would be a tough trial to get past an IRB.
It would seem like someone has got it past. Finally a prospective randomised trial of I-Gel vs intubation in OOHCA. Hurrah! http://www.airways-2.bristol.ac.uk/home/
We still do not have any evidence of survival benefit from any type of ventilation in the initial management of cardiac arrest, but we debate the best way to provide this questionable treatment. This paper is just more evidence of how little we know about the harms we are causing and the benefits we unjustifiably claim we are causing. We should be limiting ourselves to treatments with demonstrable benefit and only adding other treatments in ways that control for the variables. Currently, our uncontrolled variables include – ventilations (and all of the variations of ventilating), various drug delivery routes (various… Read more »
Agree with these sentiments.
Good info. We were in discussion of this yesterday as we trained new recruits on Supra-glottic devices. One question…….if you don’t have access to a cuff pressure measurement device and one is simply inflating i.e.: King tube according to the coloured 100ml syringe (colour markings on the syringe synonymous to the colour of the 15 ml adapter on the King) anyone know if that is close to 40cm/H2O pressure?
40 cm limit is only for the LMA, we have no idea what is the safe way of using King LT or Combitube.
i believe till conclusive results regarding safety use of supraglottic airway during cardiac arrest are published , we shall refrain from risking the brains of our patients. Most bvm studies did better that other devices in respect to long term survival.
If you truly want to go in this direction (and you v. well may be right), Ben Bobrow’s protocols in AZ of using just a NRB (I would sub in a nasal cannula at 15 lpm) may be the way to go. If you do use the NC, I would add in a few BVM breaths a minute.
Very interesting. Thanks for the pointer. Will look into this.
While its a good pointer, I’d hardly give anyone in AZ credit for that. AZ is probably the most backwards, un-insightful, slow to act system in the country.
Asha, not sure what you are referring to, but at least for Cardiac Arrest Care, it is one of the most progressive states in the US.
Is there any indication that it decreases positive neuro outcome? Ok so it looks like it decreases blood flow in a pig. Are we sure flooding oxygen rich blood into a hypoxic brain is a good thing?? Or should we cool the brain then get some oxygen rich blood back into it?
At this stage, the amount of blood hitting the brain with conventional CPR is quite low. To cut it off entirely, based on all we know, seems to be very bad for neuro outcome–but this is extrapolated, so your question is a good one.
I feel like this tells us little. First let me say I’m all about using ET tube. Having said that most of what has been found in the last two year (practical application of AHA standards) shows that prolonged intubation time are know to have a direct impact on survival. As we now know it is because of the effect it has on compressions. I think the information in this study is badly timed. As we are working very hard to keep EMS focused on aggressive compressions this seems to raise doubt. I know we are saving more lives with… Read more »
nobody wants to return to the days where we stop compressions for even 1 second to allow intubation. If there are intubation advocates after this study, then the tube must be passed without interruption of compressions. Airways used are listed above.
folks, its challenging to keep up with this all is it not! The evidence base is poor and not all that helpful to honest. Even Dr Wangs research is contradictory at times, earlier work indicating worse outcome with prehospital ETI, now this latest work that indicates a benefit.Segals work with the pigs is disturbing but insufficient to be practice changing at this moment. Who knows, maybe all the epinephrine studies in OHCA did not show a benefit because of all the SGAs placed limiting blood flow to an ischaemic brain? Paradoxically in a possible future we may return full circle… Read more »
Great podcast & discussion above. I think this study is certainly thought provoking, but I think it should be far from practice changing. Even in the discussion in the comments here, multiple knowledgable people are dismissing the results from a huge observational real world study (which I do as well- we don’t know why some got tubed and some got SGAs) while in the same breath considering changing management of real patients based on a physiology-based outcome measure on 9 animals of a different species. And while their main study graph is scary looking, the big dips are for the… Read more »
caveat: I will continue to use CVP to guide fluid therapy in standing horses.
I did not finish sorry. the longest recorded successful resuscitation of OHCA was here http://online.wsj.com/article/SB10001424052748704281504576327592395352666.html Note the pivotal role of capnopgraphy. For those who delve into the story in detail, it was winter time and snowing I believe so an element of hypothermia may have divinely assisted this mans near full recovery. Note BVM was performed mainly then converted to ETI by HEMS crew. MY Lord, even epinephrine was used then amiodarone! He is just lucky you shout back? Well if someone had not kept up to date with the role of capnography in cardiac arrest resusctiation, in other words,… Read more »
Scott,
I liked this article. Scary. Darn swine.
Clay
thanks buddy. Keep on KeepingUp.
Hello guys Thanks for listening the podcast Here is the answer to some comment. This is a provocative study, it is not done to change our practice for the moment. We must keep doing what we are doing for the moment, good CPR, short no flows and low flows, cooling. A human study is actually being done that will give more information. This study shows that we should not take for granted none prove science. We know that we can insert SGD faster and without stopping CPR, it does not prove that it improves long term survival. I continue to… Read more »
Nicolas Segal, merci Beaucoups! I enjoyed your podcast and comments here. well written and argued. COuld I ask your views /opinion on the Impedance Threshold Device and the Active Compression/Decompression device in CPR?
Bonjour Before giving my opinion I prefer to remember you that I do not have any financial conflict of interest however I have done several paper with Doctors Yannopoulos and Lurie and Dr Plaisance is my PhD director so you may consider that I have a scientific conflict of interest. I am strongly for the ITV and the ACD in particular when use together. But you need to remember that they must inside a perfect chain of survival. I have seen the results of both the ITD and the ACD on hundreds of pigs, the hemodynamic effect is really amazing.… Read more »
Hi Dr Segal, thank you for your podcast! It’s Jim DuCanto from Milwaukee (across town from Aufderheide and Lurie). You received some of my questions through Scott and addressed them in your podcast (from the Society for Airway Management Web Forum), specifically, appropriateness of the selection of SGA size for 32 kg animals, whether the head and neck anatomy was relevant to humans and were the SGA’s appropriately inflated with air, etc.. Let me first begin by congratulating you and thanking you for bringing the potential of SGA induced cerebral ischemia to everyone’s attention. I have a few simple questions… Read more »
1 unfortunately for the moment No. We do not have any more money for this study and we have use all the pigs that the ethics commitee allow us to.
2 you are correct we forget to put the breed, it was domestic crossbreed
Pouring anything in a dead pig is going to be ultrafun. You can always contact Keith Lurie (Tom Aufderheide can give you his email) and ask hiim if he is interested.
The study may be interesting .
Thank you–I’ll drop Aufderheide a note. I think we do need to standardize on the pig breed so we can get the pig-SGA right.
As we say in Wisconsin, “you-betcha’!”
Thanks Dr. Segal… We appreciate you alls work.
Matt
Good evening everyone, thank you for your insights and continued teaching. In summarizing what was posted and mentioned in the podcast, it sounds like the following plans may be reasonable:: 1)BVM and OPA with continuous chest compression cpr and minimal interruptions. 2) If advanced airway needed, ETT appears superior choice at moment, but SGA such as LMA is appropriate and LMA seems to have less carotid compression than King and Combitubes? 3) Therapeutic Hypothermia 4) Titrate ventilations to ETCo2. Does this seem to be the essence of your current thoughts and suggestions or am I missing anything? Thanks Dr Weingart… Read more »
Andrew,
Pretty good, I would reword to:
Early arrest-probably best to put on nasal cannula and maintain jaw thrust-perhaps a few breaths per minute with BVM and OPA
Prolonged Arrest-LMA with minimal inflation pressures or ET, placed without interruption of compression.
Ther hypothermia
You can’t titrate ventilations to ETCO2, in these cases ETCO2 is a perfusion marker, not a ventilation marker. Can look at the ETCO2 resp rate to make sure you are bagging slowly.
Hi Scott, I had a patient that came in after at least 30 min of asystole/PEA. I did not intubate as I thought the patient likely needed compression versus intubation. Given that the patient seem to be a difficult intubation (overweight, beard, short neck), I felt compression would help more. My question, when do you decide to intubate? that is, how many minutes of down time (for reasonable change of neurologic recovery)? Do you intubate every patient regardless of how long they have been down? What is they never had a pulse or a shockable rhythm? My colleague recommended that… Read more »
no clear answer. if there is vomit in the airway, i would intubate as soon as I ensured a source of continuous good compressions
Hope this thread is still being read. As a new Paramedic (less than one year), I really have no experience pro/con ETT vs SGA. Doesn’t Segal’s study have a glaring control problem in that all the pigs were initially started with ETT and THEN switched to a random SGA? I understand the reasoning, but in such a small model could we not have seen a few which had ETT done throughout or SGA throughout to assure that these results are not part of some progressive pathology due to length of resuscitation? Hope that didn’t sound too stupid. Thanks to all… Read more »
they returned to ETT between each SGA, which would obviate this as a confounder