What are the types of advanced airways?

Types of Advanced Airways

Advanced airways include endotracheal tubes and supraglottic airway devices such as the laryngeal mask airway (LMA), esophageal-tracheal tube (Combitube), and laryngeal tube (King LT), which are designed to maintain an open airway and facilitate ventilation during cardiac arrest and other emergency situations. 1

Endotracheal Intubation

• Endotracheal intubation involves placement of a tube directly into the trachea, providing the most secure airway with the best protection against aspiration 1
• Requires direct visualization of the glottis, which often necessitates interruption of chest compressions during cardiac arrest 1
• Confirmation of correct placement requires waveform capnography (Class I, LOE A) in addition to clinical assessment 1
• Colorimetric CO2 detectors or esophageal detector devices can be used as initial confirmation methods when waveform capnography is unavailable (Class IIa, LOE B) 1

Supraglottic Airways

Supraglottic airways are devices designed to maintain an open airway and facilitate ventilation without requiring visualization of the glottis, making them easier to insert without interrupting chest compressions 1.

Types of Supraglottic Airways:

1. Laryngeal Mask Airway (LMA)

   • Forms a seal around the laryngeal inlet without entering the trachea 1, 2
   • Suitable for routine anesthesia and emergency airway management 2
   • Limited protection against aspiration compared to endotracheal tubes 2, 3

2. ProSeal Laryngeal Mask Airway (PLMA)

   • Second-generation device with improved sealing and a gastric drainage tube 2, 4
   • Better protection against aspiration than standard LMA 4
   • Can be used during controlled ventilation 2

3. Esophageal-Tracheal Tube (Combitube)

   • Dual-lumen device that can function whether placed in the esophagus or trachea 1
   • Provides isolation of the airway and reduces risk of aspiration 1
   • Advantages over endotracheal tube related primarily to ease of training 1
   • Provides successful ventilation during CPR in 62% to 100% of patients 1
   • An acceptable alternative to both bag-mask ventilation (Class IIa, LOE C) and endotracheal intubation (Class IIa, LOE A) 1

4. Laryngeal Tube (King LT)

   • Similar to Combitube but more compact and less complicated to insert 1
   • Primarily intended as an emergency airway device 2
   • Has been successfully used during controlled ventilation in adults 2
   • May provide superior oropharyngeal seal and faster insertion in emergency situations compared to some LMAs 5

5. Video Laryngeal Mask Airways

   • Third-generation devices with integrated camera systems 6
   • Allow visualization of placement and position 6
   • May serve as conduits for endotracheal intubation under direct vision 6
   • Offer potential advantages in difficult airway scenarios 6

Advantages of Supraglottic Airways

• Do not require visualization of the glottis, making initial training and skill maintenance easier 1
• Can be inserted without interrupting chest compressions during CPR 1
• Faster insertion compared to endotracheal intubation in emergency situations 5, 4
• During CPR performed by trained providers, supraglottic airways are reasonable alternatives to bag-mask ventilation (Class IIa, LOE B) and endotracheal intubation (Class IIa, LOE A) 1

Limitations and Considerations

• No evidence that advanced airway measures improve survival rates in out-of-hospital cardiac arrest 1
• Advanced airway interventions are technically complicated and require regular practice to maintain skills 1
• Supraglottic airways generally provide less protection against aspiration compared to endotracheal tubes 2, 3
• Confirmation of proper placement is essential to prevent complications 1
• Waveform capnography should be used to confirm and continuously monitor the position of advanced airways 1

Clinical Application During Cardiac Arrest

• Once an advanced airway is in place, providers should no longer deliver cycles of CPR with pauses for ventilation 1
• The compressing provider should give continuous chest compressions at a rate of at least 100 per minute 1
• The ventilating provider should deliver 1 breath every 6-8 seconds (8-10 breaths/minute) 1
• Providers should avoid excessive ventilation rates as this can compromise venous return and cardiac output 1
• Providers should rotate roles approximately every 2 minutes to prevent compressor fatigue 1

Choosing the Appropriate Advanced Airway

• Selection should be based on provider training and experience 1
• For healthcare professionals trained in their use, supraglottic airways are reasonable alternatives to endotracheal intubation during cardiac arrest 1
• If advanced airway placement will interrupt chest compressions, providers may consider deferring insertion until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC 1
• The optimal timing of advanced airway placement during cardiac arrest remains undefined 1