Answer:
SWORBHP medical council reviewed the pros and cons to each type of airway management and we were all in agreement that SGA should be the first line advanced airway in cardiac arrest patients. When reviewing the current literature (in non-pandemic practice), overall there appears to be no mortality benefit of SGA over intubation. However, in systems that do not have a high first pass intubation success rate (>90%), the evidence would show that SGAs are the preferred airway when compared to ETTs as there is mortality benefit. Within our region, we do not have an overall first pass success rate of >90%. Therefore, this suggests that SGAs should be our first line advanced airway for both ACPs and PCPs in non-pandemic times. Medical council recognizes that prehosptial intubations are in general “difficult airways”.
Now enter the COVID-19 pandemic, the increased cognitive load of evolving practice changes, performing procedures in cumbersome PPE and now the “difficult airway” becomes an even more “difficult airway”. Hospitals across the province have recognized that intubation is probably one of the most dangerous times for aerosolization of COVID-19. As such, many hospitals have devised intubation teams to deal with all airway issues throughout the hospitals. These teams have advanced PPE, have done extensive simulation training in this PPE dealing with airway management, follow step by step airway protocols to ensure personal safety to all healthcare workers in the room. Negative pressure rooms are utilized. These teams employ rapid sequence intubation utilizing sedation and paralytic to further reduce aerosolization of virus via spontaneous respirations or reflexive coughing. Video laryngoscope (VL) is used instead of direct laryngoscopy (DL) as a safety measure by distancing the intubator from the direct line of aerosolization. In the prehospital setting, DL requires the paramedic to place their face directly into close proximity to the aerosol-generating mouth of the patient, Similarly, hospitals without Intubation teams have ED physicians practicing a near identical approach to the practices of an intubation team.
SWORBHP medical council is not alone in endorsing the use of SGAs as the first line and preferred advanced airway management strategy. BCEHS which provides medical direction to BC paramedics has restricted intubation. Alberta Health Services utilizes similar language with their COVID-19 practice changes regarding SGAs as OBHG has and strongly recommend the use of SGAs over intubation for paramedics in Alberta. Other EMS systems in the USA including Vermont and Ohio have restricted the use of ETT and utilize SGA as the preferred airway. When looking at systems that recommend intubation over SGA for advanced airway management, one has to understand the differences between those systems and the system in Ontario. For example, Medic 1 in Washington advise intubation over SGA. However, RSI is utilized in this system. Similarly the UK HEMS and Australian HEMS systems are utilizing ETT, but these systems are structured very differently than Ontario, have a different model of care and levels of practitioners on the response team, utilize different equipment, and under rigorous and extensive ongoing simulation training when it comes to airway management.
Although there may be leak from an improperly seated SGA, medical council concludes that the risk is small and that SGA should be the first line advanced airway management strategy. Medical council believes it is best for the patient and is a safer method of advanced airway management for the paramedic.
Remember that per the new OBHG memo (here), SGA and or ETT should only be considered in patients in cardiac arrest. Additionally, ventilations should be withheld when utilizing an SGA and transporting through the halls of an ED, hospital, LTC facility or public venue in the small chance that there is an air leak around the SGA. Clinical judgement should be used when transport times through these areas are long and the patient requires manual ventilation. If ventilation is required, ensure there is no one in the vicinity without proper PPE on
Intubation can be considered only as a last resort, when SGA insertion fails and/or there is airway compromise, such as the ALS-PCS contraindications to SGA insertion:
Active vomiting
Inability to clear the airway
Airway edema
Stridor
Caustic ingestion
If you do find yourself in a situation where you need to intubate, please exercise extreme caution, ensure you (and anyone within 6 feet of the patient) is in appropriate PPE (including an N-95 respirator for AGMP) and thoroughly document your reasoning for choosing intubation, which should be in line with the reasoning above.