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success of insertion, it does not have the same degree of pro- 3. Holcomb JB, McMullin NR, Pearse L, et al. Causes of death in
tection of the airway from aspiration as the LTS-D has with its U.S. Special Operations Forces in the global war on terrorism:
distal cuff in the esophagus. 2001–2004. Ann Surg. 2007;245:986–991.
4. Pannell D, Brisebois R. Talbot M, et al. Causes of death in Ca-
nadian forces members deployed to Afghanistan and implications
Our study has a number of limitations. First, the study is too on Tactical Combat Casualty Care provision. J Trauma. 2011;71
small to be able to generalize conclusions on a broad scale. (5):S401–S407.
There were only eight first-attempt insertions by medics with 5. UK Defence Medical Services. Battlefield AdvancedTrauma Life
no previous experience. It would require a larger group of Support. 4th ed. London, UK: UK Defence Medical Services;
patients to get significant evidence for the use of LTS-D and 2008.
LMA by personnel with no access to clinical airway training 6. American College of Surgeons. Advanced Trauma Life Support
(eg, first responders, junior medics, their civilian counterparts) (Student Manual). 8th ed. Chicago, IL: American College of Sur-
geons; 2008.
but who could benefit from an easy and safe airway adjunct. 7. Committee of Tactical Combat Casualty Care. http://mhs.osd.mil
Second, in this study, we used a standardized dose of fentanyl /Education_And_Training/TCCC.aspx. Accessed 8 January 2012.
1μg/kg for analgesia. Some of the patients were initially too 8. Mabry RL, Edens JW, Pearse L, et al. Fatal airway injuries during
superficially anesthetized to smoothly accept the airway ad- Operation Freedom and Operation Iraqi Freedom. Prehosp Emerg
junct. However, the light plane of anesthesia could perhaps Care 2010;14:272–277.
mirror some real-life situations where patients present with 9. Baker PA, Weller JM, Greenland KB, et al. Education in airway
management. Anaesthesia. 2011;66(suppl 2):101–111.
a lowered level of consciousness and some degree of airway 10. Dawe RJ, Mellor A. Pre-hospital anaesthesia. J R Army Med
tonus that still requires airway interventions by the medic. Corps. 2010;156(4 suppl 1):289–294.
The total dose of propofol reported in this study (2.79–11.52 11. Rieger WR, Scott SJ. Physical fitness in initial entry training. In:
mg/kg) was the accumulated dose during the entire protocol DeKoning BL, ed. Recruit Medicine. Washington, DC: Office of
including both the LMA and LTS-D insertions. Third, when the Surgeon General, Department of the US Army; 2006.
comparing insertion times in this study with previous studies, 12. Pate TH, Wenner KA, Price SA, et al. A U.S. Army forward sur-
our insertion times were longer in general. We believe this is gical team’s experience in Operation Iraqi Freedom. J Trauma.
2004;57:201–207.
because the medics in this study were themselves responsible 13. Champion HR, Bellamy RF, Roberts CP, et al. A profile of com-
for inserting the tube, cuffing, verifying adequate ventilation, bat injury. J Trauma. 2003;54(suppl 5):S13–S19.
and, if necessary, manipulating the tube to correct placement 14. Wang HE, Mann NC, Mears G, et al. Out-of-hospital airway man-
with no leakage. This may explain the longer insertion times. agement in the United States. Resuscitation 2011;82:378–385.
15. Nolan JP, Deakin CD, Soar J, et al. European Resuscitation
Council guidelines for resuscitation 2005. Section 4. Adult ad-
Conclusions vanced life support. Resuscitation 2005;67(suppl 1):S39–S86.
16. Hagberg C, Bogomolny Y, Gilmore C, et al. An evaluation of the
This study suggests that for the safe use of laryngeal tube suc- insertion and function of a new supraglottic airway device, the
tion by inexperienced airway providers, a clinical training pro- King LT , during spontaneous ventilation. Anesth Analg. 2006;
™
gram is required. The LMA proved superior to the LTS-D with 102:621–625.
a 100% success rate at the first attempt, which suggests that 17. Gaitini L, Vaida SJ, Somri M, et al. An evaluation of the laryn-
minimal training is needed before clinical use. We therefore geal tube during general anesthesia using mechanical ventilation.
Anesth Analg. 2003;96:1750–1755.
recommend the LMA as the primary airway adjunct for mili- 18. Brimacombe J, Keller C, Brimacombe L. A comparison of the
tary medics, despite a hypothetically inferior protection from laryngeal mask airway ProSeal and the laryngeal tube airway in
aspiration. Further trials with more interventions are needed paralyzed anesthetized adult patients undergoing pressure con-
to validate the efficacy of the LTS-D and the use of new LMAs trolled ventilation. Anesth Analg. 2003;96:1535.
featuring a suction channel. 19. Dorges V, Ocker H, Wenzel V, et al. The laryngeal tube: a new
simple airway device. Anesth Analg. 2000;90:1220–1222.
20. Cook TM, McCormick B, Asai T. Randomized comparison of la-
Acknowledgments ryngeal tube with classical laryngeal mask airway for anaesthesia
The authors wish to express their gratitude to Dr Jacob Karls- with controlled ventilation. Br J Anaesth. 2003;91:373–378.
son for his technical assistance and Joanna Regnér, RN, for 21. Wiese CH, Semmel T, Muller JU, et al. The use of the laryngeal
her assistance in data collection, motivation, and mentorship. tube disposable (LT-D) by paramedics during out-of-hospital re-
suscitation—an observational study concerning ERC guidelines
2005. Resuscitation. 2009;80:194.
Disclosures 22. Schalk R, Meininger D, Ruesseler M, et al. Emergency airway
The authors have indicated they have no financial relation- management in trauma patients using laryngeal tube suction. Pre-
ships relevant to this article to disclose. hosp Emerg Care. 2011;15:347–350.
23. Hubble MW, Wilfong DA, Brown LH, et al. Prehospital airway
Author Contributions meta-analysis part II. Prehosp Emerg Care. 2010;14:515–530.
DR contributed to study design, recruited patients, led and 24. Gahan K, Studnek JR, Vandeventer S. King LT-D use by urban
basic life support first responders as the primary airway device
participated in data collection, drafted the manuscript, and for out-of-hospital cardiac arrest. Resuscitation. 2011;82(12):
approved the final version of the manuscript. PF contributed 1525–1528.
to study design, patient recruitment, and data collection and 25. Dahaba AA, Prax N, Gaube W, et al. Haemodynamic and cate-
critically revised the manuscript. cholamine stress responses to the laryngeal tube-suction airway
and the ProSeal Laryngeal Mask Airway. Anaesthesia. 2006;61:
330–334.
References 26. Kikuchi T, Kamiya Y, Ohtsuka T, et al. Randomized prospective
1. Adams BD, Cuniowski PA, Muck A, et al. Registry of emergency air- study comparing the Laryngeal Tube Suction II with the ProSeal
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ways arriving at combat hospitals. J Trauma. 2008;64:1548–1554. Laryngeal Mask Airway in anesthetized and paralyzed patients.
2. Haldane AG. Advanced airway management—a medical emer- Anesthesiology. 2008;109:54–60.
gency response team perspective JR Army Med Corps. 2010;156(3): 27. Genzwuerker HV, Altmayer S, Hinkelbein J, et al. Prospective
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