Supraglottic airway and bougie: Lessons from the classroom to the field

You and your coworkers just completed in-service training on a new airway device that promises faster insertion while ensuring optimal ventilation and oxygenation for your patients with difficult airway access. You’ve completed your training, practiced your skills in the classroom, and now it’s time to take that knowledge to the field.

It’s the first call of the day, you and your partner are dispatched to the scene of an elderly male in cardiac arrest. Fire department personnel are already on the scene administering CPR when you arrive. It’s a critical moment; securing an airway is paramount in providing life-saving measures to your patient.

In most prehospital settings, endotracheal intubation is the primary method for securing an adequate airway. However, when faced with challenges, two tools can prove instrumental in securing a successful airway: bougie and supraglottic airway devices. Let’s discuss some tips to enhance provider skills in utilizing supraglottic airways and bougies.

Exploring bougies

Bougies are slender, flexible devices designed to guide the placement of an endotracheal tube during intubation.

Here are some tips for effective bougie use:

• Familiarize and practice extensively with the flexibility and behavior of the bougie to become comfortable before field use.
  
• Position the tip of the bougie just anterior to the vocal cords, and gently manipulate and rotate it to navigate airway obstructions or limited visualization of the vocal cords. If the trachea is completely occluded with a foreign object, it may be necessary to push the object to the right main bronchus to allow ventilation and oxygenation.
  
• Never force the bougie if you meet resistance. Withdraw slightly and redirect, as resistance may indicate contact with the carina or bronchus. Optimally, the bougie has an angled end called the coude tip to provide tactile feedback when moving over the semi-cartilaginous rings of the trachea, assisting in confirming tracheal placement in poorly visualized airways.

Understanding supraglottic airways

Supraglottic airways are devices that can be inserted into the pharynx to allow ventilation and oxygenation without the need for endotracheal intubation. Supraglottic airway devices are designed to maintain a clear airway by sitting above the glottis without the need for endotracheal intubation. They offer a valuable alternative when endotracheal intubation proves challenging, contraindicated or unavailable.

Here are some important tips for effective supraglottic airway use in the field:

• Assess whether supraglottic airway placement falls within the scope of BLS or ALS providers per established national/state/agency guidelines and protocols. BLS providers have demonstrated proficiency in placement and monitoring such as capnography.
  
• Put the patient first. When selecting the right airway device, size and technique is paramount. Modern advancements, including video technologies, aid in prehospital airway access. Refer to manufacturer guidelines for accurate sizing recommendations.
  
• Always ensure the patient’s head is in a neutral or sniffing position (if C-spine is not a concern) before supraglottic airway insertion, as this minimizes airway obstructions and enhances glottic alignment.
  
• Once the supraglottic airway is in place, hold it until it is secured accurately with tape or an adjustable commercial harness. Providers can consider applying a cervical collar following intubation to maintain in-line stabilization of the head and neck to diminish the possibility of tube dislodgement.
  
• Continuous monitoring is crucial, and tools like capnography provide essential feedback on the patient’s condition. Auscultation of lung sounds and visualization of the chest rise and fall are also confirmation techniques for adequate placement of the device.

Mastering airway management skills in the classroom

Here are some general tips for airway management where both supraglottic airways and bougies are used:

• Whether self-initiated or in a refresher course, continued practice with manikins and simulated scenarios is key to building confidence and proficiency.
  
• Maintaining clear, concise communication within your team is vital during airway management. Assign roles and use common language to coordinate actions.
  
• Ensure the patient is adequately pre-oxygenated before attempting intubation. This safeguard is critical if an intubation attempt takes longer than expected. Do not hesitate to reset if needed to ensure continuous oxygenation and ventilation of your patient. Once intubated, continually reassess your patient’s condition by using capnography to ensure adequate ventilation and perfusion.
  
• Conduct thorough equipment checks at the start of each shift to ensure the availability and functionality of tubes, bougies, stylets and other airway tools.
  
• Have suction readily available. It may be necessary to clear an airway prior to inserting an endotracheal tube or SGA. It may be beneficial to provide oxygen via nasal cannula if suctioning or intubation would be prolonged.
  
• Get to know your equipment thoroughly. Identify alternate plans in the classroom setting to manage complications. For example, one option may involve utilizing a CPAP mask in conjunction with the BVM to secure a tight seal, especially during challenging extrication and transport situations. This approach guarantees a consistent oxygen supply, facilitating optimal oxygenation and ventilation, including continuous capnography monitoring with little-to-no interruptions.
  
• Remain up-to-date on airway management guidelines, evidence-based research and best practices. As prehospital interventions evolve, staying informed is crucial to adapt to new techniques and challenges.

Mastering these critical skills in the classroom and field could ultimately improve patient outcomes in critical situations.

Special thanks to paramedics Andre Brooks, Ashley Morrison and Jamie Felarise for their support and use of equipment.

References

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2. Khan RM, Sharma PK, Kaul N. Airway management in trauma. Indian Journal of Anaesthesia, 55(5), 463-469. https://doi.org/10.4103/0019-5049.89870
   
3. Lyng J, Adelgais K, Alter R, Beal J, et al. Recommended essential equipment for basic life support and advanced life support ground ambulances 2020: a joint position statement. Prehosp Emerg Care. 2021;25(3):451–459. doi:10.1080/10903127.2021.1886382.
   
4. Lyng JW, Baldino KT, Braude D, Fritz C, et al. (2022). Prehospital Supraglottic Airways: An NAEMSP Position Statement and Resource Document. Prehospital Emergency Care, 26(Supplement 1), 32-41. DOI: 10.1080/10903127.2021.1983680.
   
5. Park P. (2019). Supraglottic airway devices: More good than bad. Korean Journal of Anesthesiology, 72(6), 525-526. https://doi.org/10.4097/kja.19417