The LMA requires a deep level of anesthesia (with propofol, usually), an absent gag reflex, or muscle relaxation with neuromuscular agents. In this world of new devices and rewritten rules, we now have the “rapid sequence airway.” The term was coined by Darren Braude, MD, who is an airway educator, enthusiast, and EMS director based in New Mexico. Instead of using muscle relaxants to place a tracheal tube, Dr. Braude and his flight crew have used muscle relaxants to insert a supraglottic airway (ie, a King LT-D). A similar technique has been adopted by David Duncan, MD, medical director at CALSTAR, which is a helicopter and fixed-wing service with nine bases in California. CALSTAR combines muscle relaxants on scene with insertion of a Cookgass air-Q (an LMA type device; he uses the new air-Q SP version, with a self-pressurizing cuff). Intubation can then be accomplished by the flight crew en route to the hospital if time permits. The Cookgas air-Q has significantly reduced the on-scene time for CALSTAR’s trauma patients.

In the ED, Andy Sloas, DO, an emergency physician at the University of Kentucky in Lexington, has been using LMAs after administration of muscle relaxants for years. Once ventilation and oxygenation are stabilized, he uses the LMA as a mucus-free conduit to intubate—combining an endoscope with an Aintree catheter passed via the LMA channel. Though Dr. Sloas’s practice is uncommon in the ED setting, intubation through the LMA with endoscopy is widely done in anesthesia.

Airway management is evolving rapidly; we are beginning to rethink the rules laid down 30 years ago (pre-LMA, pre-video laryngoscopy, pre-nasal oxygen during efforts securing a tube [NO-DESAT] or apneic oxygenation via nasal cannula during intubation). There are now second- and third-generation supraglottic airways, which permit effective ventilation and gastric decompression. Some of these include the Ambu Aura-GAIN, the Cookgas air-Q SP, the Intersurgical i-gel, the LMA Supreme, and the King LT-D. Many of these devices also serve as great conduits for intubation with endoscopes.

Dr. Levitan is an adjunct professor of emergency medicine at Dartmouth College’s Geisel School of Medicine in Hanover, N.H., and a visiting professor of emergency medicine at the University of Maryland in Baltimore. He works clinically at a critical care access hospital in rural New Hampshire and teaches cadaveric and fiber-optic airway courses.

What do these new rules and devices mean for practicing emergency physicians?

Here are a few take-home points: