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Supraglottic airways (SGAs)

First off, a little bit on the (potentially confusing) terminology: Since we all like acronyms in medicine you'll often hear any supraglottic airway referred to as an 'LMA', short for laryngeal mask airway, as in "... let's use an i-gel LMA". These days 'LMA' is a registered trademark for a company that makes the LMA Unique® or LMA Supreme® for example. Therefore you should avoid the term 'LMA' unless you are talking about supraglottic airways made under this particular trademark. The correct umbrella term for all these devices is 'supraglottic airway' (SGA) or, also common, 'supraglottic airway device' (SAD).

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 Supraglottic airway devices: more good than bad

SADs can be used for airway rescue in difficult airway situations, such as “cannot intubate, cannot ventilate.” They can rescue emergent situations when traditional attempts to ventilate or oxygenate the patient fail. Both the difficult airway algorithm by the American Society of Anesthesiologists and Difficult Airway Society 2015 guidelines suggest the use of SADs for airway rescue in such scenarios. In addition, SADs can be used for advance airway management in patients with out-of-hospital cardiac arrest, although their functional outcome was not favorable 30 days after the out-of-hospital cardiac arrest compared to tracheal intubation.

Articles of Interest

ETI vs. SGA: The Verdict Is In

Many EMS agencies have recently switched to an alternative SGA, the i-gel. A similar trial called “The Airways-2 Randomized Clinical Trial” in the United Kingdom compared i-gel with intubation in OHCA.9 Their findings suggest that there are no significant differences at hospital discharge or 30 days after arrest for all trial patients.

Managing the out-of-hospital extraglottic airway device

Extraglottic airway devices (commonly referred to as supraglottic airway [SGA] devices) play an integral role in the prehospital airway algorithm as a primary airway device or as a rescue airway after failed intubation. Recently, two large, randomized controlled trials and a large meta-analysis have demonstrated that, for a variety of medical conditions, SGAs are noninferior to endotracheal intubation with respect to survival-to-discharge, survival with good neurological outcome and first-pass success

Research Analysis: Key takeaways from PART and Airways-2 Trials

Comparing endotracheal, laryngeal tube and supraglottic airway device intubation during out of hospital cardiac arrest

Supraglottic Airway Devices

SADs now provide successful rescue ventilation in > 90% of patients in whom mask ventilation or tracheal intubation is found to be impossible. However, some concerns with these devices remain, including failing to adequately ventilate, causing airway damage, and increasing the likelihood of pulmonary aspiration of gastric contents. Careful patient selection and excellent technical skills are necessary for successful use of these devices.

Supraglottic Airway Devices for Pediatric Airway Management in the Emergency Department

Types of SGAs that are commonly used in pediatric patients (including the LMA® Classic™, intubating LMA/LMA® Fastrach™, LMA® ProSeal™, LMA® Supreme™, Combitube®, laryngeal tube airway/King LTS-D™, i-gel®, and Baska Mask®). Supraglottic airways are a group of airway devices used to secure a patient’s airway or as an aid to facilitate endotracheal intubation (ETI). The term supraglottic indicates that these devices sit just above the larynx and allow for oxygenation and ventilation. These devices are sometimes referred to as “extraglottic” instead of “supraglottic.” For the purposes of this article, these devices will be referred to as supraglottic airway devices (SGAs).

Supraglottic Airway Review

With a multitude of extraglottic devices on the market the LMA and LT remain the most common in the prehospital setting due to simplicity of use and reliability. For pediatric use, the LMA has the largest range of sizes and clinical literature backing its use, although no large prehospital studies have been performed. BVM should still function as the best and most reliable means of ventilating a child in the prehospital environment.

Supraglottic Airways as Intubation Aids

The ability of SGAs to ventilate anesthetized patients is an accepted clinical fact, but it was their ability to assist me in managing difficult tracheal intubations that led me to fully “deep dive” them as a clinical tool.

Supraglottic Airways: Use in Cardiac Arrest Remains Controversial

It was recently reported that SGAs can improve outcomes vs. an ET tube in patients with a cardiac arrest, but another large study from the same time period in Great Britain found no difference when either adjunct was applied early in the treatment of cardiac arrest. Importantly, more than 90% of all patients treated in both studies still died from cardiac arrest, regardless of the type of airway adjunct deployed.

The Role of the LMA as a Ventilating and Intubation Conduit During Emergency Airway Management

The supraglottic airway device (SAD) has earned a well-regarded position in both anesthesia care and emergency airway management. Its prominent position in various societal algorithms for rescue airway management is testimony to its ubiquitous availability, its relative ease of use, and relatively high success rate under adverse clinical conditions.

Utilizing a Supraglottic Airway Device as an Intubation Conduit

Introduced in 1988, the supraglottic airway (SGA) device or laryngeal mask airway (LMA) was invented by Dr. Archie Brain and underwent testing among more than 7,000 patients prior to its commercial launch. Its invention was spawned from a need for an airway device separate from an endotracheal tube (ETT) or face mask. Since then, the LMA has undergone many changes with currently three recognized SGA generations.