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The Fastrach Intubating Laryngeal Mask -excerpt from my Prehospital Anaesthesia syllabus

The Fastrach Intubating Laryngeal Mask Airway (ILMA)

- carried by RFDS Queensland and Western Australian sections and is highly recommended for pre-hospital settings. Several published prospective studies from French pre-hospital systems certainly support its efficacy both as a rescue ventilation and intubation device. It can also be used as your primary intubation tool if chosen and research in the elective anaesthesia setting has found it to be similar success to gold standard flexible fibre optic bronchoscopy in the predicted difficult intubation patient, with a success rate in one study of 99% intubation within 2 attempts. Disposable versions are recommended in the prehospital setting as well as the specially designed wire reinforced, soft tip endotracheal tube that accompanies the device. This specially designed endotracheal tube has excellent characteristics for general emergency airway use, including a soft tip which makes it preferable for bougie assisted intubations andtube exchanges.

 

(Fastrach special tracheal tube on left and normal tube on right)

It is recommended that if it is used as a pre-hospital primary or secondary rescue airway for intubation, that once achieved no attempt is made to remove the ILMA as per manufacturer’ instructions. Unless one is very experienced in doing this, it offers little advantage in the pre-hospital and retrieval setting and risks losing the airway you have worked hard to gain!

 This does create a unique problem if the ILMA and tracheal tube are left in situ during transport : how to best secure both? RFDS experience is that using two separate lengths of ribbon tape is best. One is used to tie around the patient’s neck and around the shaft and handle of the ILMA (see pictures below).

 

The second tape is used to tie around the tracheal tube.

The tube and LMA are then tied together as one unit. If the tube needs to be urgently removed , its tie can be cut quickly but the LMA is still securely tied in place. Or if the tube and LMA need to be both urgently removed then only the tube cuff needs deflating and the LMA tie cut and then both devices can be removed at the same time.

Generally it does not matter if you leave air in the ILMA mask or aspirate it during aeromedical transport to altitude. RFDS experience of flights up to 2 hrs. in duration with the ILMA sitting in the oropharynx with the air it was originally inflated with, has found no issues in regard to pressure induced trauma or loss of adequate airway positioning. If there is a concern for flights of longer duration then deflating the ILMA mask is reasonable. Certainly it is not advised to fill the ILMA mask with saline as is sometimes the practice for tracheal tube cuffs. One disadvantage is it only comes in 3 sizes for adults.

Minh’s tips for successful airway management with the ILMA

-lubricate the tube channel of the ILMA by coating the tube with lube and inserting and withdrawing the tube several times into the channel

-use the Chandy maneuver to ensure proper positioning and application of the ILMA to the larynx, for both ventilation and blind intubation.

- the tube exits the bowl of the ILMA at 18cm mark of the silicone tipped ETT. If you encounter resistance at that mark then reposition the ILMA by slightly withdrawing and try passing tube again.

-watch Dr Chandy Verghese  intubate himself awake using the ILMA!

Prehospital articles of note

From Spain

From UK

From France

7 Comments Post a comment
  1. Only problem I have with the FastTrach is that doesn’t have an NG port. Sure, you can withdraw the iLMA over the ETT to allow passage of a NGT (or OGT) but there have been some spectacular airway ‘fails’ doing this, as the technique of obturating the ETT and removing the LMA is a fiddle

    I wonder how you feel the FastTrach compares to the AirQ II with it’s NG channel and somewhat less acute angle for bougie/ETT tube passage

    I’m thinking of chucking the FastTrachs in favour of the Air Q II on our trolley/prehospital pack…but I will keep the flexible ETTs as they are really good, as you point out

    Thoughts?

    May 30, 2012
    • Tim, Jim, great questions and comments!
      It really depends upon what you feel comfortable with. If seeing is believing then AirQ will allow you to use an optical sytlet or fibreoptic scope or VL to visually guide a tube or bougie much better than the Fastrach. From an evidence based viewpoint, its a clear winner in my view. There is much more published out of operating room, prehospital literature on the efficacy of the Fastrach ILMA than the AirQ. Even the published operative room anaesthetic literature demonstrates that for blind intubation the Fastrach is a clear winner over the AirQ.

      Overall I agree that the AirQ II has advantages over the Fastrach. Its a bit cheaper and allows intubation with standard tubes as well as having a gastric drain port and blocking balloon. However the Fastrach comes as a complete device in allowing ventilation as well as blind intubation. One prehospital doctor I know uses it exclusively in prehospital intubations and does not use a laryngoscope anymore. I am not saying that is what I recommend but the point is the Fastrach can do the job of two devices ( LMA and laryngoscope) whilst the AirQ can really only do the job of one.

      Also in prehospital work I like the handle of the Fastrach and being able to manipulate the device once inserted into the mouth and applying it towards the larynx for better ventilation and intubation success. Its biggest downfall is that it does not come in smaller sizes for paediatric patients…so its not going to replace your laryngoscope completely is it!

      Tim, for you, the AirQ and King vision are going to be fine. You could handle pretty much everything that is humanely possible via the mouth with those two devices. Add a Levitan stylet in and it would be complete the package..thats a complete package for prehospital and inhospital airway crises for under $4000. just need the surgical airway kit to be an all rounder.

      May 31, 2012
      • kangaroobeach #

        “just need the surgical airway kit to be an all rounder.”

        Hopefully not!

        Been in this situation x5 now, I think thats enough!

        Anyhow, I;m a scalpel-bougie/finger-ETT chap…I think we’ve discussed this before!

        May 31, 2012
  2. Jimmy D #

    Before I begin my comments, I must disclose that I am an Anesthesiologist, and am highly biased in favor of the Air-Q (you could call me an early adopter–I used them as early as 2004). The Fastrach was introduced in the States the year I left training, so the unfortunate truth is that I never learned how to effectively perform the blind intubation maneuvers with this device–so I don’t like it and I don’t trust it. I am highly biased against this device for these reasons, also, I progressed from the level of proficiency to mastery of the flexible fiberoptic bronchoscope early in my career, and thus, the idea of non-visualized tracheal intubations gives me an allergy attack.

    The Air-Q II is the next generation is simplicity, form and function. It facilitates guided (and I emphasize visualized guidance here) with a plethora of devices. Let’s leave flexible scopes out of the discussion. Back in late 2004, I discovered that the Levitan optical stylet can perform the task of guidance through the Air-Q quite nicely. Recently, I discovered that pretty much any video laryngoscope can perform this function as well, passing the tracheal tube through the central channel, then endoscopy over the heel of the mask for guidance.

    I realize that you want a simple solution, but your colleagues may want the Fastrack system around due to their familiarity. Choose a solution that respects the needs of the greater good, and in the meantime, practice intubation through the Air-Q II with a variety of devices so that when the time comes, you are ready. All you can do is work on yourself, your techniques and your readiness.

    One topic that has not been discussed with these devices is that in cases of intramural/pharyngeal bleeding, these devices may provide the platform to hold direct pressure on the site of bleeding, while providing a clean, clear path the to the larynx—providing the ability to suction through the devices to clear the airway of blood, vomit, fluid, etc.. The Air-Q has such a large internal diameter that it provides the user the ability to suction through it with a standard Yankauer suction catheter. Try it first in simulation. This is a big upgrade in SGA capability–the ability to use suction like this.

    Anyway, I just want to contribute to Mihn’s blog in any positive way I can to give you guys potentially useful solutions. I do a lot of difficult airway management within my anesthesia practice (my partners give me most of the recognized DA cases), and the “center” around which most of my approaches now “orbit” is the Air-Q (also with an Oxylator–more on that some other time).

    May 31, 2012
  3. Thanks, all good points, espec pharyngeal bleeding. Must practice with a Yankauer down the lumen of the AirQ…

    Very helpful stuff, all this. Dunno about the rest of you, but these blogs and tips are really helping me question my practice and explore options…whoch is a good thing.

    Hopefully others are doing same, particularly us rural blokes who are looking for robust yet affordable solutions when thio-sux-tube doesn’t always work out! Reckon the concepts here are wellsuited to hands on sessions with the gear in small group scenario-based sessions – Minh, your STAR programme is excellent.

    May 31, 2012
  4. Adam Hagar #

    For those of us who very occasionally perform DL and rely primarily on simulation to maintain intubation “proficiency”, would your experience with these type of intubating LMA’s suggest that these devices used in conjunction with ETI may be preferred over DL from a pt safety perspective?

    November 15, 2012
    • thankyou for an excellent question, Adam!
      you have just inspired my next podcast.. the occasional intubator Part 2!

      November 15, 2012

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