UMEM Educational Pearls

Title: Supraglottic airways to prevent aerosol spread during chest compressions in the COVID-19 era.

Keywords: airway management, cardiac arrest, COVID-10, SARS-CoV-2, cardiopulmonary resuscitation, CPR (PubMed Search)

Posted: 11/3/2020 by Kami Windsor, MD
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As the number of COVID-19 cases rises worldwide, prehospital and emergency department healthcare workers remain at high risk of exposure and infection during CPR for patients with cardiac arrest and potential SARS-CoV-2.

Existing evidence supports similar cardiac arrest outcomes in airways managed with a supraglottic airway (SGA) compared to endotracheal intubation (ETT).¹ It is generally accepted that the best airway seal is provided with endotracheal intubation + viral filter, but how well do SGAs prevent spread of aerosols?

In CPR simulation studies:

Cuffed endotracheal tube + viral filter provides effective seal to prevent aerosolization during CPR.²
SGA + viral filter decreases AP spread compared to facemask and compared to bag-valve mask ventilation during CPR.³
Notable aerosolization is seen with SGAs, with no difference between AuraGain, I-gel, LMA Proseal, LMA Supreme, Combitube, or LTS-D.²

Bottom Line:

Ventilating through an SGA + viral filter is likely better to limit spread of aerosolized particles than bag-valve mask ventilation.
SGAs allow egress of aerosolized particles, although the amount and area of distribution in clinical practice is unclear, and endotracheal intubation with a cuffed endotracheal tube remains the best way to avoid ongoing aerosolized particle spread with chest compressions.
Appropriate PPE remains crucial to limiting healthcare workers' risk of infection and must be prioritized, even/especially in the management of patients in cardiac arrest.

References

Benger JR, Kirby K, Black S, et al. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018;320(8):779-91. doi: 10.1001/jama.2018.11597.
Somri M, Gaitini L, Gat M, et al. Cardiopulmonary resuscitation during the COVID—19 pandemic. Do supraglottic airways protect against aerosol-generation? Resuscitation. 2020. doi: 10.1016/j.resuscitation.2020.10.013
Ott M, Milazzo A, Liebau S, et al. Exploration of strategies to reduce aerosol-spread during chest compressions: A simulation and cadaver model. Resuscitation. 2020;152:192-8. doi: 10.1016/j.resuscitation.2020.05.012