What is the preferred method of airway management between King airway and intubation in a cardiac arrest situation?

King Airway vs. Intubation in Cardiac Arrest

During cardiac arrest, supraglottic airways such as the King Laryngeal Tube are a reasonable alternative to endotracheal intubation, with both methods considered acceptable for airway management based on provider training and experience.

Comparison of Airway Management Options

Endotracheal Intubation

• Provides the most secure airway with best protection against aspiration 1, 2
• Enables delivery of a selected tidal volume and provides an alternative route for drug administration 1
• Requires more advanced skills and training to perform correctly 1
• May lead to interruptions in chest compressions during insertion attempts 2, 3
• Associated with complications when performed by inexperienced providers, including unrecognized esophageal intubation 1
• Requires confirmation of placement with waveform capnography (Class I, LOE A) 2

King Laryngeal Tube (Supraglottic Airway)

• Can be inserted without direct visualization of the vocal cords 1, 2
• Generally faster to place than endotracheal tubes 4
• Requires less training to use effectively 1
• Can be inserted without interrupting chest compressions 2
• Provides effective ventilation during CPR in most cases 1
• Does not provide absolute protection against aspiration 1

Evidence on Outcomes

• Recent meta-analysis of randomized controlled trials found that supraglottic airways probably increase return of spontaneous circulation (ROSC) compared to endotracheal intubation (RR 1.09; 95% CI, 1.02-1.15) 4
• Supraglottic airways can be placed faster than endotracheal tubes (mean difference 2.5 min less; 95% CI, 1.6-3.4 min less) 4
• No significant difference in survival to hospital discharge between supraglottic airways and endotracheal intubation (RR 1.06; 95% CI, 0.84-1.34) 4
• The AIRWAYS-2 randomized controlled trial found no significant difference in neurological outcomes at 30 days between supraglottic airways and endotracheal intubation 5
• Some observational studies have shown improved outcomes with endotracheal intubation over supraglottic airways 6

Current Guideline Recommendations

• The American Heart Association states that for healthcare professionals trained in their use, supraglottic airways are a reasonable alternative to bag-mask ventilation (Class IIa, LOE B) and endotracheal intubation (Class IIa, LOE A) for airway management during cardiac arrest 1, 2
• The King Laryngeal Tube may be considered as an alternative to bag-mask ventilation (Class IIb, LOE C) or endotracheal intubation (Class IIb, LOE C) for airway management in cardiac arrest 1
• Provider experience and training should guide the choice of advanced airway 1, 2

Important Considerations

• Successful ventilation rates with the King Laryngeal Tube range from 85-97% in cardiac arrest settings 1
• Once any advanced airway is placed, providers should deliver continuous chest compressions without pauses for ventilation 2
• Ventilation should be delivered at 1 breath every 6-8 seconds (8-10 breaths/minute) 2
• Avoid excessive ventilation rates as this can compromise venous return and cardiac output 2
• Frequent training and experience are essential for maintaining skills with any advanced airway technique 1

Potential Complications to Monitor

• Esophageal trauma with supraglottic airways 1
• Unrecognized misplacement of endotracheal tubes 1
• Prolonged interruptions in chest compressions during intubation attempts 2, 3
• Regurgitation and aspiration with either method, though rates appear similar between the two approaches 5

Conclusion

The choice between King Laryngeal Tube and endotracheal intubation should be based primarily on provider training and experience. Both are acceptable options for airway management during cardiac arrest, with neither showing clear superiority for survival outcomes 1, 5, 4.