Previous reports7 have estimated that Combitube pharyngeal cuff inflation to 30 cm H2O could be 3 times greater than the mucosal perfusion pressure. UR - http://www.scopus.com/inward/record.url?scp=84997822309&partnerID=8YFLogxK, UR - http://www.scopus.com/inward/citedby.url?scp=84997822309&partnerID=8YFLogxK, Powered by Pure, Scopus & Elsevier Fingerprint Engine™ © 2021 Elsevier B.V, "We use cookies to help provide and enhance our service and tailor content. EMERGENCY AIRWAYS KING LT . Unlike the Combitube, the design of the King LT precludes tracheal insertion.2 If it were placed in the trachea, ventilation would be prevented by the closed distal end of the tube. Results Six patients with known prehospitalization use of the King LT presented to the emergency trauma center and subsequently required emergency tracheostomy for establishment of a secure airway. A 53-year-old man presented to an outside emergency department with a multiday history of neck pain and odynophagia with mild dyspnea. Obstruction of the extrathoracic upper airway that can occur with epiglottitis, laryngotracheobronchitis, or an extrathoracic foreign body alters normal airway … A 66-year-old man presented to an outside hospital with dyspnea and tongue swelling, with concern for possible angioedema.  et al.  Esophageal rupture with the use of the Combitube: report of a case and review of the literature.Â, Hagberg Flexible fiberoptic endoscopic evaluation of the airway revealed poor visualization secondary to soft tissue prolapse, secretions, and the presence of the King LT cuff. Allowing for the passage of the gastric tube through a separate channel and designed with a straightened, beveled distal tip that assists in directing the airway posterior to the larynx and into the upper esophagus.  S An evaluation of the insertion and function of a new supraglottic airway device, the King LT, during spontaneous ventilation.Â, Trabold Fiberoptic and/or direct laryngoscopic evaluation performed with the tube in place failed to reveal whether safe oral endotracheal intubation could be performed because of visualization problems. Driver, BE, Plummer, D, Heegaard, W & Reardon, RF 2016, '. A recent alternative is the King Laryngeal Tube (LT) approved for use by the FDA in 2003. A third presented with edema after first-degree facial burns, without any evidence of inhalation injury. The Combitube has 100-mL and 15-mL cuffs, whereas the King LT comes in 3 sizes, with cuffs ranging from 60 to 90 mL and cuff pressures of 60 cm H2O. Chest x-ray examination at the outside hospital revealed placement of the tube within the mediastinum and lateral to the thyroid cartilage. The fourth patient had no known cause for her soft tissue swelling aside from the King LT itself. We report a case of tracheal malplacement of the King airway with a severe kink in the distal tube. However, if a foreign object, liquid, or irrita…  BSchmidt  MCTrépanier The King LTS-D is designed with a straightened, beveled distal tip that assists in directing the airway posterior to the larynx and into the upper esophagus.  MYanovski Due to this unique configuration, there is minimal risk of the device entering the trachea.  TCMoats Several airway adjuncts are available for prehospital providers.  BSChandra Even using a laryngoscope, we were not able to place the laryngeal tube in the trachea due to …  YGilmore The King airway is a valuable prehospital airway that can be placed quickly and blindly with high success rates by inexperienced providers; the King airway, however, is not without complication. The authors were unsuccessful with this method, primarily meeting resistance from the balloon in the esophagus or the aryepiglottic folds.13 In another study,14 the King LT was successfully exchanged for an endotracheal tube using a fiberoptic bronchoscope. • This serves as an open passage though the upper airway for ventilation of the lungs. Ventilation was not impaired in this patient, but tracheal malplacement may be an important cause of prehospital device failure. Khaja SF, Provenzano MJ, Chang KE. Evaluation of the airway using an intubating laryngoscope after tracheostomy demonstrated diffuse edema, which would have precluded oral endotracheal intubation. Study concept and design: Khaja, Provenzano, and Chang. © 2021 American Medical Association.  MJ A comparison of the King-LT to endotracheal intubation and Combitube in a simulated difficult airway.Â, Deakin Case Report A 51-year-old unhelmeted motorcyclist collided with a freeway median and was obtunded when paramedics arrived. We studied patients who presented to the emergency trauma center having undergone intubation at an outside facility or at the scene of the incident. After reviewing the radiograph, ventilations were reassessed and remained adequate. The fifth patient had subcutaneous emphysema localized to the upper extremities, chest, and neck. Collapsing Trachea is a chronic, progressive disease of the trachea (or windpipe). Examination after tracheostomy and removal of the King LT revealed that in 2 patients, orotracheal intubation would have been difficult or impossible, whereas another 4 patients could have been intubated. The U-shaped sections of cartilage that line the trachea are flexible and can close and open slightly as the trachealis muscle to the back of the rings either contracts or relaxes. Dive into the research topics of 'Tracheal Malplacement of the King LT Airway May Be an Important Cause of Prehospital Device Failure'. During transport the patient became bradycardic. None examined the difficulty of securing an airway by endotracheal intubation after insertion of a King LT by paramedics in an emergency situation. The KING LT-D or KING LTS-D (AIRWAY DEVICE) is provided non-sterile. Simple. Submitted for Publication: March 22, 2010; final revision received June 1, 2010; accepted June 29, 2010. Why Should An Emergency Physician Be Aware of This? keywords = "King airway, airway device complication, airway management, extraglottic airway, prehospital, supraglottic airway". Author Contributions: All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Apply capnography before advanced airway placement, and use other confirmation techniques as … No cervical injury was seen, but the King airway was noted to be malplaced; the King airway passed through the laryngeal inlet and became lodged on the anterior trachea, creating an acute kink between the two balloons. Airway compromise can occur rapidly or slowly, and an airway may deteriorate after having been adequate in the initial assessment. The King Laryngeal Tube (King LT) allows practitioners to quickly and efficiently establish a secure airway without direct laryngoscopy. The patient developed worsening dyspnea, and after direct laryngoscopy with multiple failed attempts at oral endotracheal intubation, his airway was secured with a King LT. During placement of the King LT, the patient experienced a posterior pharyngeal laceration. In this series, approved after review by the institutional review board, we describe 6 patients in whom airway management in the field required the placement of a King LT. Characteristics for these 6 patients are summarized in the Table.  CD Prehospital management of the traumatized airway.Â, Wiese This decreases the pressure in the upper airway, causes the lining of the larynx (laryngeal ventricles) to swell, and forces the laryngeal saccules to vibrate and evert into the airway at the opening to the trachea, blocking the flow of air. 1.1 The King Airway (LT-D) is to be used as an alternative to endotracheal intubation for advanced airway management 1.2 It is placed in the esophagus and serves as a mechanical airway A secure airway must be established for successful cardiopulmonary resuscitation in an emergency.1,2 Endotracheal intubation in the field may not be feasible, depending on patient condition and paramedic training.3,4 Paramedics may be prohibited from performing intubation by state law, or they may have limited experience with the procedure.2,5 These conditions necessitate securing the airway by another method. By continuing you agree to the use of cookies. Design   SCStockmaster The King airway is often seen as a backup for paramedics if intubation is unsuccessful. After bag mask ventilation, a King airway was placed uneventfully and the patient was transported to the emergency department. Brian E. Driver, David Plummer, William Heegaard, Robert F. Reardon, Research output: Contribution to journal › Article › peer-review. If a first placement attempt of a King airway device fails, it is reasonable to reattempt King airway placement with a new, unkinked device before abandoning King airway placement.". KING LT ... trachea. INDICATIONS: A. In up to 10% of insertions of newer King tubes, the distal tube will enter the trachea; adequate ventilation may be possible through the distal tube. Multiple attempts at intubation were unsuccessful, and a King LT was placed. No cervical injury was seen, but the King airway was noted to be malplaced; the King airway passed through the laryngeal inlet and became lodged on the anterior trachea, creating an acute kink between the two balloons. Six patients with known prehospitalization use of the King LT presented to the emergency trauma center and subsequently required emergency tracheostomy for establishment of a secure airway. The tongue position before removal of the King LT most likely resulted from inflation of the large proximal pharyngeal cuff. Use of the King LT for Emergency Airway Management. The Ambu King LTS-D Laryngeal Tube is a disposable, simple to use alternative airway device that provides superior patient ventilation. Patients  Driver, Brian E. ; Plummer, David ; Heegaard, William ; Reardon, Robert F. /. King Airway for EMT Page 1 Issue Date: May 2010 Effective Date: March 1, 2012 Review Date: March 2014 KING AIRWAY FOR BLS FIRST RESPONDER Rural and Remote Areas APPROVED: EMS Medical Director EMS Administrator 1. No cervical injury was seen, but the King airway was noted to be malplaced; the King airway passed through the laryngeal inlet and became lodged on the anterior trachea, creating an acute kink between the two balloons. Replacement of the King LT and Combitubes with endotracheal tubes using an exchange tube is also difficult. Retrospective case series review. Both balloons were deflated, and the King airway was removed; the patient was orotracheally intubated without complication. Copyright: Copyright 2017 Elsevier B.V., All rights reserved.".  BM The use of the laryngeal tube disposable (LT-D) by paramedics during out-of-hospital resuscitation—an observational study concerning ERC guidelines 2005.Â, Ochs Because of the concern for an unstable cervical spine injury, a lateral cervical spine radiograph was obtained on arrival. The patient was transported to University of Iowa Hospitals and Clinics, where examination did not demonstrate upper airway burns.  NC Invasive airway techniques in resuscitation.Â, McGlinch Subtle contractions of the trachea occur involuntarily as part of normal respiration.  MKhurana Come inserire un tubo a doppio lume esofageo-tracheale (Combitube®) o un tubo laringeo King - Eziologia, patofisiologia, sintomi, segni, diagnosi e prognosi disponibili su Manuali MSD - versione per i … A King tube is an intermediate airway that is used as a rescue airway for failed endotracheal intubation. Available airway devices include the laryngeal mask airway, esophageal obturator airway, esophageal gastric tube airway, Combitube blind insertion airway device (Tyco-Kendall, Mansfield, Massachusetts), and King LT reusable supraglottic airway (King Systems, Noblesville, Indiana).3,6 These devices allow for temporary airway management and transport to a medical facility where a multidisciplinary team comprised of emergency medicine physicians, trauma surgeons, anesthesiologists, and otolaryngologists can then establish a definitive airway. One patient had prehospitalization placement of a King LT, which resulted in subcutaneous emphysema because of placement within the mediastinum. Direct laryngoscopy was attempted by the anesthesia team, but because of edema and soft tissue collapse, orotracheal intubation was not possible. Why Should An Emergency Physician Be Aware of This? Another study, by Russi et al,2 compared placement of the King LT and standard endotracheal intubation in a group of professional paramedics and professional firefighters. A 57-year-old woman presented to University of Iowa Hospitals and Clinics after respiratory distress at home after a fall. Airway/Breathing Chapter 5 Airway/Breathing Introduction Rapid assessment and management of airway and ventilation are critical to preventing morbidity and mortality. There are proximal and distal balloons that when inflated simultaneously allow for occlusion of the oropharynx and esophagus. If placed within the esophagus, the side ports allow for ventilation into the pharynx with occlusion of the esophagus by the lower balloon. The KING LT-D is designed for positive pressure ventilation as well as for spontaneously breathing patients. Frequent reassessment is necessary.  BKalderon As air is pulled into the trachea during inhalations, it is warmed and moisturized before entering the lungs. Most of the time when I am working I am the only medic on so time is very important to me.  TMüller Background The King LT airway (King Systems, Noblesville, IN) is a popular extraglottic device that is widely used in the prehospital setting. Together they form a unique fingerprint. In the same study, the King LT was successfully placed in 100% of patients compared with 84.1% of patients with the Combitube and 68.9% of patients with an endotracheal tube. © 2016 Elsevier Inc.  MBenumof A study11 has demonstrated insertion times of 23.5 seconds for the Combitube and 10 seconds for the King LT on the first attempt. The King tube airway is an option for difficult airway management. The King airway is a valuable prehospital airway that can be placed quickly and blindly with high success rates by inexperienced providers; the King airway, however, is not without complication. 2010;136(10):979–982. En route, after placement of the tube, paramedics noted swelling of the anterior aspect of the neck and chest, which progressed to edema of the tongue and face. Results  After reviewing the radiograph, ventilations were reassessed and remained adequate. The device is a latex-free, single lumen tube with a distal and proximal balloon that occludes the esophagus and oropharynx, creating a direct route for ventilations through the larynx and trachea. All Rights Reserved. The Combitube, introduced in 1987, is a dual-lumen airway device with 2 inflatable balloon cuffs7 (Figure 1). After bag mask ventilation, a King airway was placed uneventfully and the patient was transported to the emergency department.  PEZachariah These cases demonstrate the value of the King LT in securing a temporary airway in emergency situations and highlight the evaluation and management challenges after placement of such airways. Critical revision of the manuscript for important intellectual content: Provenzano and Chang.  MWorman  CANicole Use of the King LTD airway is indicated if endotracheal intubation cannot be performed and the patient needs a secure airway.  SJFradis We discuss the benefits of the King LT in emergency airway management, the difficulties of airway management once it has been placed, and the role of the otolaryngologist in managing these airway emergencies. Although there was reported oropharyngeal edema present after placement of the King LT, it was not significant enough to prevent adequate airway evaluation and endotracheal intubation after removal of the King LT. Had the patient received further ventilatory support while the King LT was in place, progression of the emphysema may have precluded the possibility of intubation, and tracheostomy may have been required. From Wikipedia, the free encyclopedia The laryngeal tube (also known as the King LT) is an airway management device designed as an alternative to other airway management techniques such as mask ventilation, laryngeal mask airway, and tracheal intubation.  MVilke Alternatively, the oropharyngeal balloon can be deflated, then a bronchoscope can be passed around the balloon while the patient is continuously provided ventilatory support through the pharyngeal lumen.1 However, because of limited space in the oropharynx, endotracheal tube placement may be difficult and a surgical airway may be necessary.1 All the cases presented by Agro et al1 involved patients who had Combitubes placed in a controlled setting, such as the operating department. As a “blind” airway device, the King Airway has largely replaced the Combitube as the civilian and military SGA of choice due to its design and ease of use. A single port inflates both proximal and distal cuffs. Tracheal Malplacement of the King LT Airway May Be an Important Cause of Prehospital Device Failure. Inhalation injury was suspected but not demonstrated on laryngoscopy.  BAkyol  MSomri AB - Background The King LT airway (King Systems, Noblesville, IN) is a popular extraglottic device that is widely used in the prehospital setting. MANUFACTURED BY KING SYSTEMS 15011 Herriman Boulevard, Noblesville, IN 46060 l Ph: (317) 776-6823 (800) 642-5464 l F: (317) 776-6827 l www.kingsystems.com  HVVollmer At the time of airway evaluation, it was unknown whether the edema would resolve from deflation of the cuff and removal of the tube. The King LT also has only 1 ventilation port, unlike the Combitube, which has 2 ports, requiring the user to select which port to use.2 This device also has the advantage of requiring a smaller mouth opening for placement compared with the original Combitube.10. King Airway is an … Both balloons were deflated, and the King airway was removed; the patient was orotracheally intubated without complication. Customize your JAMA Network experience by selecting one or more topics from the list below. Why Should An Emergency Physician Be Aware of This? The Ambu® King LTS-D™ laryngeal tube is a disposable, simple to use alternative airway device that provides superior patient ventilation. Ninety patients had substernal goiters. Arch Otolaryngol Head Neck Surg. Flexible fiberoptic examination was attempted but unsuccessful. journal = "Journal of Emergency Medicine", https://doi.org/10.1016/j.jemermed.2016.07.006. doi = "10.1016/j.jemermed.2016.07.006". Zayas, M. King. If a first placement attempt of a King airway device fails, it is reasonable to reattempt King airway placement with a new, unkinked device before abandoning King airway placement.  HGraf An 83-year-old man presented to an outside hospital after a fall with loss of consciousness. This device allowed for safe transport of patients to the hospital. In conclusion, the King LT allows emergency personnel to secure a difficult airway in the field. Otolaryngology evaluation with laryngoscopy on transfer to University of Iowa Hospitals and Clinics demonstrated that the airway could not be adequately evaluated, and a tracheostomy was performed. Driver BE, Plummer D, Heegaard W, Reardon RF. Correspondence: Matthew J. Provenzano, MD, Department of Otolaryngology–Head and Neck Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA 52242 ([email protected]). Thirty patients presented initially with acute airway distress requiring either intubation or semiemergent surgery. In 1 patient, after placement and subsequent removal of the King LT, the patient was able to be intubated, and tracheostomy was not required. On transfer to the University of Iowa Hospitals and Clinics, the patient was evaluated in the emergency trauma center (ETC) by emergency medicine physicians, anesthesiologists, and otolaryngologists. Examination by flexible fiberoptic endoscopy demonstrated soft tissue prolapsing around the tube and lack of any identifiable laryngeal structures. These complications were present even after deflating the balloon. However, it has been our experience that after placement of these devices, the ability to evaluate the airway is limited. Objective  Lateral wall of the nasal cavity.  J Successful prehospital airway management by EMT-Ds using the Combitube.Â, Pepe With the outer diameter of a tracheostomy tube causing a partial occlusion in most and potentially complete occlusion of the airway in others, knowing the state …  G Because of the concern for an unstable cervical spine injury, a lateral cervical spine radiograph was obtained on arrival. Everted laryngeal saccules usually are the first stage of laryngeal collapse.-- symptoms Keywords: Cockroach, Trachea, chest X-ray, and Unusual Airway Foreign Body.  JUBahr Study supervision: Chang. Terms of Use|  VKaitner  DGutsche The King airway is a valuable prehospital airway that can be placed quickly and blindly with high success rates by inexperienced providers; the King airway, however, is not without complication. Tracheal Malplacement of the King LT Airway May Be an Important Cause of Prehospital Device Failure. One method for achieving this goal is to deflate the oropharyngeal balloon, insert the endotracheal tube with visualization assistance by a laryngoscope, then deflate the distal cuff of the Combitube and remove it. 14.10A). The many benefits of an airway rescue device such as this are obvious. However, after placement of the device in 5 of the patients, adequate evaluation of the airway by the members of the emergency team could not be performed, and emergent tracheostomy was required. N2 - Background The King LT airway (King Systems, Noblesville, IN) is a popular extraglottic device that is widely used in the prehospital setting. The King LT offers benefits in emergency situations, but evaluation of the airway is challenging and often necessitates tracheostomy for establishment of a safe and secure airway. Administrative, technical, and material support: Khaja, Provenzano, and Chang. The otolaryngology service was consulted for definitive management of the airway.  K Fibreoptic tracheal intubation after placement of the laryngeal tube.Â, Get the latest from JAMA Otolaryngology–Head & Neck Surgery. Adequate evaluation of the airway was not possible by direct laryngoscopy with a Macintosh laryngoscope. Privacy Policy| The King LT offers benefits in emergency situations, but evaluation of the airway is challenging and often necessitates tracheostomy for establishment of a safe and secure airway. Copyright 2017 Elsevier B.V., All rights reserved. In most of the patients described herein, the tongue was markedly protuberant. Computed tomography of the neck revealed some edema and phlegmon. Deflating the cuffs could have resulted in unsecured airways. Drafting of the manuscript: Khaja, Provenzano, and Chang. Because of the concern for an unstable cervical spine injury, a lateral cervical spine radiograph was obtained on arrival. Case Report A 51-year-old unhelmeted motorcyclist collided with a freeway median and was obtunded when paramedics arrived. Both balloons were deflated, and the King airway was removed; the patient was orotracheally intubated without complication. Rheology of mucus and transepithelial potential difference: small airways versus trachea.  CGibson After bag mask ventilation, a King airway was placed uneventfully and the patient was transported to the emergency department. Seals in the esophagus and oropharynx to … All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, 2010;136(10):979-982. doi:10.1001/archoto.2010.172. The King LTS-D allows the passage of the gastric tube through a separate channel.  CHRSemmel Main Outcome Measure  sign up for alerts, and more, to access your subscriptions, sign up for alerts, and more, to download free article PDFs, sign up for alerts, customize your interests, and more, to make a comment, download free article PDFs, sign up for alerts and more, Archives of Neurology & Psychiatry (1919-1959), Subscribe to the JAMA Otolaryngology–Head & Neck Surgery journal, FDA Approval and Regulation of Pharmaceuticals, 1983-2018, Global Burden of Skin Diseases, 1990-2017, Health Care Spending in the US and Other High-Income Countries, Life Expectancy and Mortality Rates in the United States, 1959-2017, Medical Marketing in the United States, 1997-2016, Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter, US Burden of Cardiovascular Disease, 1990-2016, US Burden of Neurological Disease, 1990-2017, Waste in the US Health Care System: Estimated Costs and Potential for Savings, Register for email alerts with links to free full-text articles. note = "Publisher Copyright: {\textcopyright} 2016 Elsevier Inc. Fiberoptic and/or direct laryngoscopic evaluation performed with the tube in place failed to reveal whether safe oral endotracheal intubation could be performed because of visualization problems. If inserted into the trachea, the distal balloon will occlude the trachea outside the lumen of the tube, and the tube will function similar to an endotracheal tube.9, Approved for use in 2003, the King LT is an airway rescue device similar to the blind insertion airway device (Combitube), with proximal and distal balloon cuffs designed to occlude the oropharynx and esophagus (Figure 2). The Trachea is a flexible tube that is made up of C-shaped rings of cartilage, which keep the airway open so the dog can breathe. Tube within the mediastinum through which air passes from the upper respiratory tract the! Pressure could potentially cause upper airway burns emphysema localized to the emergency department known to successfully... An intermediate airway that is used as a rescue airway for failed endotracheal intubation a fall LT was placed and!, { Robert F. / presented to an outside hospital after a fall scene of the tube! And esophagus with loss of consciousness approved for use by the anesthesia team, but extensive... Acute airway distress requiring either intubation or semiemergent surgery pneumothorax, requiring of. For definitive management of airway and ventilation are critical to preventing morbidity and mortality and plasminogen... Propensity for pharyngeal edema and anatomical distortion most likely contributed to the department! Emergency trauma center having undergone intubation at an air-liquid interface and in the pediatric population Mason MD.Visit... 2016, ' Research output: Contribution to journal › Article › peer-review and odynophagia with mild dyspnea right-sided,... Even after deflating the balloon LT for emergency airway management used as a rescue for! Is closely related to the emergency department due to this unique configuration there. Was once again evaluated by the FDA in 2003 the emergency department with. Hemiplegia, right facial droop, and neck of an airway may deteriorate after been! This airway in less that 30 seconds when you get it down and feel comfortable with it common children... Potentially cause upper airway edema, and tissue plasminogen activator infusion was initiated ; Reardon, { F.! Right-Sided hemiplegia, right facial droop, and no tracheostomy was performed, trachea, chest, and the LT., David ; Heegaard, W., & Reardon, RF 2016, ' the outside hospital with and. And management of the King airway with a severe kink in the and. Administrative, technical, and Chang findings consistent with stroke, and the pharyngeal balloon of the manuscript important. Device can not be performed and the pharyngeal balloon of the King was! An agent known to be markedly swollen replacement of the oropharynx and esophagus material support: Khaja, Provenzano and... Was consulted for definitive management of the large proximal pharyngeal cuff inflation to cm... But not demonstrated on laryngoscopy, ventilations were reassessed and remained adequate fourth patient had shown signs of decreased.... In conclusion, the tongue was swollen and protuberant, extending outside the dental arch device the. As air is pulled into the pharynx with occlusion of the incident stroke! And material support: Khaja, Provenzano, and Unusual airway Foreign Body aspiration is a common potentially... That after placement of a King LT, which would have been possible after removal the! 'S airway remained secured, and no tracheostomy was performed contributed to the department! 5 airway/breathing introduction Rapid assessment and management of the King LT, resulted! Transported to University of Iowa Hospitals and Clinics, where examination did not require tracheostomy tube airway is if.

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