We use in our medical pre-hospital emergency service Airtraq in difficult airway management, especially in trauma patient. Never is the first choice in CPR, we always try to intubate and after this, we use Fastrach laryngeal mask also for intubate. If we cannot manage the airway with these methods we consider using Airtraq.

Thanks José

Do you mean LMA CTrach. Useful though expensive.

We use a video laryngoscope as our back up device. The airtraq is, I believe, similar to the glidescope but without a "screen". We decided that our back-up device should not require a significantly different technique to our common approach, hence the video laryngoscope. In a difficult airway situation we didn't want to swap from our familiar device/approach to something that feels very different and is less familiar. The video laryngoscope feels/handles like a regular laryngoscope and gives us an assisted, superior, view in difficult situations.

Thanks Matthew

I've worked with video laryngoscope and have found it easy to handle.

It is possible to use screen for Airtraq via an attachable camera, though I think then we have something very similar to first generations of video laryngoscope: as expensive and as cumbersome. However, the visor of Airtraq itself is helpful enough most of the time without distracting us from the field of practice to check the view. New generations of video laryngoscope are probably like airtraq so just the price matters. I have no experience with these new ones with in built screen.

Video enabled laryngoscopy and intubation could be useful in case of emergency however, How rugged should the devices be built? Is videolaryngoscopy an early or the last aid for intubation. What is the place for laryngeal masks in this flow chart. How experienced can an emergency professional become for safe use of videolaryngoscopy. Most importantly, for a good field of view, you might need a big screen. Such a setting is feasible in an Operation Theatre, but not at noon on the highway with an incarcerated patient who might be vomiting because of his/her neurotrauma.

We think that is almost impossible to use a videolaringoscopy in out-of-hospital medicine. Perhaps Glydescope could be an option, but the airway in these situations is always full of blood or vomit. Of course we can aspirate and clean the lenses, but we need a very quick answer and no time lost is possible. This is the principal reason we use the Fastrach LMA with the possibility of intubate the patient and isolate completely the airway. In our experience we use the same Fastrach for several patients after a sterilization process. You can read our article about our experience with the Fastrach LMA in the difficult out-of-hospital difficult airway management.

Thanks José, thanks Sven

I agree that using video laryngoscopes (including Glydescope) as well as airtraq is sometimes difficult in trauma patients. Meanwhile, as we need a secure airway in such patients intubation is mandatory when GCS is low. So Fastrach LMA (or iLMA) is a good choice. Provided that we have a clear field, the literature looks like support using Airtraq in prehospital setting and with navices:

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2007.05215.x/abstract

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2007.05263.x/abstract

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2011.06871.x/abstract

Airtraq devices are of value as a second attempt in mildly difficult airway management, in real difficult cases you have to use other devices such as video assisted devices or fibroscopy. One point could be difficult with airtraq is tube insertion , we find it easier to insert first an ET introducer then insert the ET . I advice to use the airtraq after training on patients with no difficult intubation. Difficult intubation materials should include all devices in order to change in case of difficulty, moreover airtraq is not suitable in traumatic previous intubation or facial trauma patients as blood and deformation are major risk factors for failure, Finally there is is no prefered device for difficult airway management every situation has it device. Regards

There is plenty of evidence suggesting that videolaryngoscipes are more successful at managing difficult airway (when difficulty is defined by limited view at Macintosh laryngoscopy). Choosing the videolaryngoscope that you have some experience in using in normal airways is important point mentioned previously as almost all videolaryngoscopes require some adjustment to your intubation technique.

I would disagree though with ILMA (Fastrach LMA) being selected as suitable device for use in failed intubation. This device has to be used with the guidance of fibreoptic scope if it is to be effective (UK DAS guidelines). A number of surveys in the UK pointed towards limited experience with this device. Blind intubation through the ILMA has a success rate of around 80% - not enough for a failed intubation rescue device. Fibreoptic guided intubation through ILMA has much higher success rate but requires significant amount of training before proficiency is achieved.

I would argue that learning to use a videlaryngoscope is much simpler and easier than learning to intubate through ILMA with fibreoptic guidance.

Use of Airtraq and Pentax AWS in the prehospital setting is now well researched and supports the use of these portable devices that are shock and water resistant to a reasonable degree.

Thanks Iljaz,

Though the benefits of Airtraq in prehospital setting is documented, there are still debates on using Airtraq in emergency situations in hospital. Difficult airway management is the most important concern of anesthesiologists and the guidelines are not helpful sometimes as attached recent interesting review shows. I agree that we should use a device that we are more familiar with in daily practice and this means that there may be no unique method for difficult airway management.

With regard to Airtraq I've had difficulty inserting larger sizes tube and I found it useful to insert an introducer first as Bassam mentioned. Besides, I've discussed that Airtraq prevents from damage to soft tissue and teeth specially in patients with maldentitions which is commonly seen in our daily practice.

https://www.researchgate.net/publication/232278700_Prevention_of_tooth_and_gum_damage_novel_application_of_airtraq_laryngoscope

https://www.researchgate.net/publication/233968319_Prevention_of_tooth_and_gum_damage_an_oft_neglected_advantage_of_indirect_laryngoscopy_with_Airtraq

Article Prevention of Tooth and Gum Damage: Novel Application of Air...

Article Prevention of tooth and gum damage: an oft neglected advanta...

In our hospital setting first choice for out of the ICU or ER airway management is a laryngeal tube. Especially in cardiac arrest patients you should not waist time trying to etablish a patent airway. In our intra-hospital CPR-courses we teach the use of the laryngeal tube. Most of the nurses and doctors with little intubation practice can manage an airway with this device without time delay in 95% . No-Flow-Time during CPR is decreased because you do not have to search for the cords.That's why actual ERC-Guidelines included the use of LT.

Endotracheal intubation as a first choice is only performed by our intensivists or ER-physicians. My first choice after one failed attempt is a frova cath introducer to intubate the trachea. Second choice is bronchoscopic guidance.

I only have two experiences with Airtraq Device and was not really convinced. Both times i could not visualize the cords because the optic was blured by blood-streaked sputum after first laryngeal introduction

En mi hospital el Airtraq está, tanto en el carro de parada como en el de vía aérea difícil, y lo considero de elección si no hay problemas de ventilación. Si los hay eligiria la MCL Fastrac

Antón Arizaga answer in English (using google translate with modifications). Is it correct?

In my hospital the Airtraq is used both in the trolley and in the difficult airway, and for elective cases with no ventilation problems. If there is no option pick the MCL Fastrac

Ha habido un error de traducción. He querido decir que en mi hospital se usa tanto en el carro de vía aérea díficil como en el carro de parada. Un saludo.