The classic laryngeal mask airway has been recommended as a ventilatory device for out-of-hospital cardiopulmonary resuscitation by several international resuscitation councils, including the American Heart Association . However, there are only four out-of-hospital studies describing its use as a ventilatory device [2-5]. The intubating laryngeal mask airway Fastrach™ (ILMA) has greater potential than the LMA™ for out-of-hospital cardiopulmonary resuscitation, as it forms a more effective seal with the glottis , insertion is quicker and ventilation is easier , it is easier to insert in the neutral position  and it is a more effective airway intubator . There is one study describing the successful use of the ILMA as a ventilatory device (100%) and for blind tracheal intubation (72%) after failed rapid sequence induction by air medical personnel . In the following study, we test the feasibility of using the ILMA as a ventilatory device and for flexible lightwand-guided tracheal intubation for out-of-hospital cardiopulmonary resuscitation by an emergency physician.
The study was approved by the National Emergency Pre-hospital Service of North Greece Ethics Committee. A single, experienced emergency physician (GV) underwent training for an airway management technique that involved flexible lightwand-guided tracheal intubation via the ILMA. Training comprised 1 h of practice on a manikin and 30 supervised insertions in anaesthetized patients. This technique was used for all out-of-hospital bystander-witnessed cardiac arrests requiring tracheal intubation over a 10-month period.
The technique comprised: (i) inserting the ILMA using a single handed rotational technique from above the head of the patient, (ii) inflating the cuff to the maximum recommended volume, (iii) attaching a self-inflating bag and commencing ventilation, (iv) removing the self-inflating bag and inserting a well-lubricated, straight silicone tracheal tube preloaded with the flexible lightwand into the ILMA airway tube, (v) advancing the tracheal tube beyond the epiglottis elevating bar while observing the glow in the neck and (vi) reattaching the self-inflating bag and recommencing ventilation if the tracheal tube easily advanced 8 cm beyond the ILMA. If a glow could not be seen, the skin over the neck was stretched. Whenever slight tactile resistance was felt or the light glow was not correctly located, a predetermined sequence of adjusting maneuvers was instituted (Table 1). If oesophageal intubation occurred, the ILMA was partially withdrawn and the handle extended before a second attempt. If this failed, the ILMA was partially withdrawn and reinserted before a further attempt. In between intubation attempts the patient was ventilated with the ILMA. An intubation attempt via the ILMA was defined as a forward and backward movement of the tracheal tube. A maximum of three attempts was allowed to insert the ILMA. An insertion attempt was defined as rotation of the ILMA towards the pharynx. Successful placement or the ILMA and tracheal tube was judged by chest wall movement. The maximum number of intubation attempts allowed was 5. A size 4 ILMA size 7 mm tracheal tube was used in female and a size 5 and a size 8.0 mm in male. The head/neck was in the neutral position, if possible. If access to the head was limited, ILMA insertion and intubation were conducted from below or to the side of the head. Cricoid pressure was avoided during use of the ILMA.
The number of attempts at ILMA placement, the number of attempts at tracheal intubation and the time taken to intubate the patient were noted. Intubation time was from picking up the ILMA to successful tracheal intubation. In addition, data were collected about gender, body habitus (thin, normal, overweight), age range (21-30, 31-40, 41-50, 51-60, 61-70, 71-80, 81-90), the aetiology of the cardiac arrest (spontaneous or trauma), the time taken for the ambulance to reach the patient, whether the patient was being face mask ventilated by paramedics upon arrival, whether or not access to the head and neck was limited, and whether or not circulation was successfully restored. All data were collected by the investigator.
There were 37 patients: 28 male and 9 female. The number of thin, normal and overweight patients was 10, 15 and 12, respectively. There were 4 patients aged 21-30, 3 aged 31-40, 2 aged 41-50, 11 aged 51-60, 8 aged 61-70, 5 aged 71-80 and 4 aged 81-90. In 25 patients the cardiac arrest was spontaneous and in 12 it was related to trauma. The mean (range) time for the ambulance to reach the patient was 12 (10-20) min. Face mask ventilation was being attempted by paramedics upon arrival in 13/27 (35%). The ILMA was successfully inserted at the first attempt in 35/37 (95%) and at the second attempt in 2/37 (5%). The mean (range) intubation time was 70 (45-110) s. The tracheal tube was successfully inserted in 25/37 (67.5%) at the first attempt, 7/37 (19%) at the second attempt and 5/37 (13.5%) at the third attempt. There were no overall failures for ILMA insertion or tracheal intubation. There were no differences in success rate between positions. Oesophageal intubation occurred in 2/37 (5%) and was easily corrected. The position of the investigator was above the head in 29/37 (78%) and below and to the side in 8/37 (22%). Circulation was successfully restored in 7/25 (28%) after spontaneous cardiac arrest and 3/12 (25%) after trauma.
We found that the ILMA has a high success rate as a ventilatory device and as an flexible lightwand-guided airway intubator during out-of-hospital cardiopulmonary resuscitation by ambulance medical personnel. Gibbs and colleagues  reported a similarly high success rate as a ventilatory device (100%) but a slightly lower success rate as an airway intubator (82%) during out-of-hospital cardiopulmonary resuscitation by air medical personnel after failed laryngoscope-guided tracheal intubation. Our higher success rate as an airway intubator may be related to using a guided rather than a blind technique. A meta-analysis of the literature has shown that lightwand and fibreoptic-guided techniques have a higher success rate than the blind technique . We did not use the fibreoptic technique as it is unsuitable for out-of-hospital resuscitation. Our success rate as a ventilatory device and as an airway intubator was similar to studies using this technique for anaesthetized patients with normal [11,12] and abnormal airways . The frequency of oesophageal placement was also similar to previous studies of anaesthetized patients [11-13].
Airway management is notoriously difficult in patients who are trapped in motor vehicles. Laryngoscope-guided tracheal intubation, for example, is difficult without the operator being able to position themselves above the patient's head, though some success has been reported using the laryngoscope in the ice-pick position . We found that the ILMA has a high success rate with the investigator below and to the side in situations of limited access. This has been previously reported for the classic laryngeal mask airway , but not for the ILMA. We described the successful use of the ILMA for airway rescue in two patients the lateral position  and subsequently showed that insertion of and flexible lightwand-guided intubation through the ILMA was similarly highly successful in the supine, right and left lateral positions in healthy patients by experienced users . There are several reports of the classic laryngeal mask airway being inserted in the lateral and prone positions . The successful use of the ILMA with a stereotactic frame in situ has also been reported . We consider that the ILMA may have a particular role for airway management during cardiopulmonary resuscitation when there is limited access to the head and neck. This technique may be unsuitable in situations where there is limited mouth opening and/or the head neck is in the chin-to-chest position, as the ILMA may be difficult to insert . Also, if cardiopulmonary resuscitation is outside and/or during daylight hours, the light glow might be difficult to see and intubation reduced to a blind technique. Cricoid pressure was not used, as it interferes with insertion and intubation .
Our study has two limitations. First, all insertions were performed by a single experienced medical practitioner who received extensive training with the technique and our results may not be applicable to less experienced and less well-trained practitioners. However, it has been shown that nursing staff have a high success rate with this technique in anaesthetized patients after a 2 h training programme . Second, all data were collected by the investigator, a possible source of bias. Further studies are required to determine the utility of this technique by other personnel, the level of training required to acquire and retain skills, its success rates compared with other techniques, such as laryngoscope-guided tracheal intubation and other airway intubators, and whether success rates are influenced by ambient light.
We conclude that the ILMA has a high success rate as a ventilatory device and as a flexible lightwand-guided airway intubator during out-of-hospital cardiopulmonary resuscitation by a well-trained emergency physician. This technique may be particularly useful where there is limited access to the head and neck.
Conflict of interest statement
Dr Brimacombe has previously worked as a consultant for the Laryngeal Mask Company and Mallincrodt Medical. Dr Dimitriou and Dr Voyagis are the inventors of the flexible lightwand. This study was supported solely by departmental funds.
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