Supraglottic Airway Devices

Why you should make them your best friend

Mastering Your Upper Airway Lifelines - SGA Edition.006

In the emergency setting, the supraglottic airway (SGA), is one of the three upper airway lifelines available to help you maintain lifesaving oxygenation in a patient who needs positive pressure ventilation (PPV). Along with the bag valve mask (BVM), and the endotracheal tube (ETT), it’s another essential tool to protect your patients from hypoxic injury and death.

While there are various types of SGAs, the primary benefit of all of them is the same: they provide an effective and efficient way to achieve adequate oxygenation for your patient without having to enter the trachea. This defining characteristic of an SGA makes it invaluable in an airway emergency because it can be placed rapidly and doesn’t depend on laryngoscopy.

Mastering Your Upper Airway Lifelines - SGA Edition.007

Despite expanding from their routine use in the operating room for elective procedures into the hands of first responders and emergency providers, they’re still encountered infrequently in the emergency setting. And because the SGA sits further down on most emergency intubation algorithms its frequently perceived as primarily an intubation rescue device (see algorithm below).

The truth is that in the emergency setting, the SGA is better thought of as primarily an oxygenation rescue device: one that can be used at any point in the management of an apneic or hypoxic patient who needs rescue oxygenation. The best representation for this role of the SGA that I’ve seen is in the Vortex Approach created by Dr Nicholas Chrimes @NicholasChrimes and is shown below, as one of three equally effective upper airway lifelines available to you. The Vortex places the SGA within a mental model that works much better for the purposes of emergency airway management, taking it out of the restrictive confines of the difficult airway algorithm.

While it may be one of the three upper airway lifelines considered equally effective for the purposes of oxygen delivery, in many circumstances it may be the most rapid and effective of all the tools available to you for the following reasons: by creating a seal over the glottic opening, the SGA eliminates the need to create a good face mask seal, and it bypasses the upper airway structures that can cause airway obstruction and delay oxygen delivery during BVM use.

Compared to the ETT, it’s not considered a “definitive” airway, but it can reduce gastric insufflation and aspiration risk without requiring laryngoscopy, which makes its effective time to adequate oxygenation the most consistent and rapid of all the upper airway lifelines in an emergency. An experienced provider can place an SGA in under 3 seconds.

Like any tool, there are some other drawbacks that should be considered with its use: because it’s placed over the glottic opening, it can’t be used on an awake patient, or in someone with an intact gag reflex, and there are also some important contradictions to SGA use that can be easily remembered using the RODS mnemonic.

Mastering Your Upper Airway Lifelines - SGA Edition-3.001

By now it should be clear that the SGA can be your friend in an airway emergency far beyond its use as an intubation rescue device sitting down there towards the end of the difficult airway algorithm. The use of an SGA should be considered in any of the following situations:

Failure to oxygenate your patient after best effort with a BVM
As the initial oxygen delivery device for the cardiac arrest patient
As the initial device for the unresponsive morbidly obese patient
Patients with beards or in whom a face mask seal is predicted to be difficult
In resource poor settings in order to free up a set of hands.

The bottom line. In many airway emergencies the SGA can consistently provide rapid and effective oxygenation and in some situations, may be superior to BVM or ETT placement as the first option. So if you’re looking for an oxygenation delivery tool that’s rapidly placed, effective, easy to learn, prevents gastric insufflation, and frees up your hands to do something else for you patient, then don’t neglect the SGA as part of your training or your practice!

The FOAM Bundle for the SGA

There is a lot of great FOAM education on this topic, so we’ve gathered some the best here for you to learn from. Start by watching this great overview by Dr Andrew Brainard at The Sharp End and then head over to our Flipboard magazine for more bundled FOAM content.