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