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Airway Articles that Should Change Your Practice

Braude, Darren MD, EMT-P

Emergency Medicine News: May 2009 - Volume 31 - Issue 5 - p 4
doi: 10.1097/
The Emergency Airway

Dr. Braude is an associate professor of emergency medicine at the University of New Mexico School of Medicine, the medical director for PHI Air Medical of New Mexico, both in Albuquerque, a co-director of Airway911 and the National Procedural Sedation Course (, and the author of a new book, Rapid Sequence Intubation, now available at



Plenty of interesting airway articles were published last year, although none were “landmark” papers. I only wish more came from the emergency medicine literature.

Rocuronium versus Succinylcholine for Rapid Sequence Induction Intubation

Perry JJ, et al

Cochrane Database Syst Rev


The conclusion of this Cochrane review, that succinylcholine produces superior intubation conditions compared with rocuronium, is very misleading. In the subgroup that received the appropriate dose of rocuronium for emergent RSI (0.9 to 1.2 mg/kg), there was no statistical difference between succinylcholine and rocuronium. Dose is a critical factor with any competitive neuromuscular blocker. While practitioners can continue to debate the relative risks and benefits of succinylcholine and rocuronium, intubating conditions produced by the two medications should not be one of the factors.

Reversal of Profound, High-Dose Rocuronium-Induced Neuromuscular Blockade by Sugammadex at Two Different Time Points

Puhringer FK, et al



If you are a succinylcholine advocate, your primary argument is most likely the safety margin of the short duration. While I do not personally believe this is a significant concern during emergency RSI with the immediate availability of extraglottic rescue airways, the argument will disappear completely when sugammadex becomes clinically available. This latest trial confirms that sugammadex can reverse full RSI doses of rocuronium (see above) in under two minutes. That makes succinylcholine look like the long-acting agent.

Laryngoscopy Force in the Sniffing Position Compared to the Extension-Extension Position

Lee L, Weightman WM



These authors have demonstrated the effectiveness of the “extension-extension” position, achieved by placing a pillow behind the shoulders, using the proxy measure of intubation force in a small group of patients. This is not the same as leaving the head flat on the bed and cranking back. This paper emphasizes the underappreciated importance of head positioning during intubation. I still start with the sniffing position (or ramped, if obese) in medical patients. If that and external laryngeal manipulation don't reveal the cords, reposition. That may mean hyperelevation, placing the head flat, or elevation-elevation.

Effects of Head Posture on the Oral, Pharyngeal and Laryngeal Axis Alignment in Infants and Young Children by Magnetic Resonance Imaging

Vialet R, et al

Paediatr Anaesth


Now, a pediatric perspective to further reinforce the importance of proper head positioning. While adults, adolescents, and older children are best served by the discussion above, children require different positioning. While this paper is looking at alignment rather than the more important clinical issue of laryngoscope view, it emphasizes that the optimal position for infants and toddlers is slight extension of the head. This is achieved with a towel roll behind the shoulders for infants and the head flat on the bed for toddlers.

A Prospective, Randomized Comparison of Cobra Perilaryngeal Airway and Laryngeal Mask Airway Unique in Pediatric Patients

Szmuk P, et al

Anesth Analg


Comparison of the CobraPLA and the Laryngeal Mask Airway Unique in Children under Pressure Controlled Ventilation

Gaitini L, et al

Paediatr Anaesth


The actual results of these two trials are less important than the fact that there are expanding options for pediatric extraglottic airways and clinical comparisons now underway. The PLA slightly outperformed the LMA-Unique, but the latter will soon be replaced clinically, in my opinion, by the LMA-Supreme. We will need to await future comparisons of these and other pediatric devices. For now, every ED must have at least one of the available pediatric extraglottic airways immediately available.

Evaluation of the Airtraq and Macintosh Laryngoscopes in Patients at Increased Risk for Difficult Tracheal Intubation

Maharaj CH, et al



Comparison of the Glidescope, the McGrath, the Airtraq and the Macintosh Laryngoscopes in Simulated Difficult Airways

Savoldelli GL, et al



Ah, the inevitable demise of the laryngoscope. When the stakes are as high as the airway, it is surprising the resistance many practitioners have to giving up their traditional and now outdated tools. These are two of many papers that demonstrate the superiority of video, fiberoptic, and optically-enhanced laryngoscopy. No single device has clearly come out on top. Which device to buy depends on your budget and preferences.

The Effectiveness of Noninvasive Positive Pressure Ventilation to Enhance Preoxygenation in Morbidly Obese Adults

Delay JM, et al

Anesth Analg


In April 2006, I reviewed a paper by Bailard et al on the benefits of using noninvasive positive pressure ventilation (NIPPV) to preoxygenate for RSI. This new paper looks specifically at obese adults and again finds benefit. It is clear that preoxygenation is critical to keeping the patient safe and allowing the intubator sufficient time during RSI. It makes sense that NIPPV would be a useful adjunct. There is no excuse not to put hypoxic patients on NIPPV, even if you feel intubation is inevitable, unless the patient requires bag-valve-mask ventilation.

A New Single Use Supraglottic Airway Device with a Noninflatable Cuff and an Esophageal Vent: An Observational Study of the i-gel

Richez B, et al

Anesth Analg


Evaluation of the i-gel Airway in 300 Patients

Bamgbade OA, et al

Eur J Anaesthesiol


The i-gel is one of the newer devices competing in the rapidly expanding market of extraglottic airways. It is unique because it does not require inflation. Many emergency physicians may not realize the impact that over- or under-inflating a laryngeal airway may have on the seal. A device that negates this issue would be useful if it could provide a consistent tight seal. Neither of these studies has proven the i-gel to be ready for emergency use. The best extraglottic device for emergency use is still unknown, though devices that facilitate decompression of the stomach through a dedicated channel (LMA-Supreme, LMA-ProSeal, King LTS-D and i-gel) are particularly appealing.

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