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developed or adopted to deal with the unique circumstances Based on our data, we would encourage healthcare providers
of terrorist attacks in civilian settings. to use NVG while placing SADs to achieve a patent airway if
tactical issues require working in low-light conditions.
To support those efforts, it is necessary to perform further
studies to increase the level of evidence concerning the field of In our setting we did not use additional IR light sources, so we
tactical medicine regardless of whether the setting is civilian or estimate that the position of rescuers would not be revealed,
military. Additionally, this helps to secure the attention of the and situational awareness of the immediate surroundings
relevant scientific societies on this subject. could be maintained. This would not be the case, for instance,
when work is performed under a large blanket as proposed by
This study focuses on a certain subset of tactical patient care. Bilge et al. 8
It was conducted to investigate the feasibility of using different
SADs, using a manikin with NVG in low light conditions. Among the various SADs, the i-gel LMA had significantly
shorter placement times than the LTS or the conventional LMA.
The NVG used in our study are regularly employed by Ger- The i-gel LMA has a cuff filled with thermoplastic gel. At body
man armed forces and law enforcement agencies. Increasingly, temperature, this cuff conforms to fit the anatomic structures of
tactically trained rescue personnel are supporting special oper- the hypopharynx, creating a seal. Unlike the LTS and the LMA,
ation forces of the police in missions. RAID, the Special Forces the i-gel does not require additional inflation, thereby further
unit of the French police, and the Special Weapons and Tactic simplifying the procedure. For personnel wearing NVG, this
teams (SWAT) of the police in the Rhineland-Palatinate are is important. NVG restrict the field of view to approximately
just two examples. 50° and also impair three-dimensional vision. Third-generation
NVG users have a clear image only for a pre-focused area, sim-
The type of airway management largely depends on the situ- ilar to a camera without an autofocus function.
ation. When a tactical advantage has been achieved, the ca-
sualty must be evacuated from the danger zone as quickly as According to a meta-analysis by Park et al., there is no sig-
possible. An immediate goal in this phase is to control critical nificant difference in leak pressure between the i-gel and the
bleeding. Airway management is deferred until the phase of LMA. The type of cuff does not appear to have a clinically
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tactical/prolonged field care. relevant impact on ventilation. Problems such as upper airway
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edema, which is associated with the LTS, are not expected
In recent years, SADs have become more widely used in both because of the thermoplastic low-pressure cuff and have also
civilian and military rescue services because of their reliability not been reported in previous i-gel use, even in children, with
and ease of use. Most civilian and military rescue personnel are their significantly more vulnerable mucous membranes. 20
considered to have a low level of proficiency performing endo-
tracheal intubation or cricothyroidotomy, because exposure to Schmidbauer et al. conducted a study on human cadavers,
these procedures is uncommon in their day-to-day activities. evaluating the protection from aspiration with different types
Professional associations regard SAD as a tool for securing the of SAD. The LTS and the LMA were found to have an ad-
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airway that can be used safely even by less experienced us- vantage compared with the i-gel, which was investigated sep-
ers and therefore recommend its primary use especially with arately. The second-generation i-gel SADs were able to ensure
predicted difficult airways and for healthcare providers with rapid and sufficient drainage of gastric contents through a
limited experience in airway management techniques. 16,17 stomach tube, which prevented aspiration sufficiently. 22

Confirming the applicability of SADs used in conjunction Limitations
with NVG was an operational necessity for the field of tacti- Since we used a manikin, our study has known limitations re-
cal emergency care. Our study shows that the use of an NVG garding the applicability of results to living persons. 23
has a measurable impact on the speed of placement but does
not prolong the placement to a clinically significant extent. In The focus of our investigation, however, was to evaluate dif-
addition, there was no significant difference for each SAD in ferent SADs for airway management with NVG and to iden-
placement success in ambient light and with NVG. tify potential system-specific complications before patients are
involved. For this reason, the study setting was suitable. Since
All participants were able to read the size information on the the placement times and success of the various SADs are com-
various SADs when wearing NVG and were able to make a parable to the results obtained in other studies on manikins,
proper size selection. It would, however, increase efficiency if we can assume a comparable transferability to living persons.
additional size markings were added to the product.
A short-term training effect was noted because all participants
The results of this feasibility study indicate that there would had the opportunity to use each SAD once under ambient light
be a positive impact for healthcare providers and their patients conditions before using it with NVG. That may have influ-
using NVG during airway management procedures in low- enced the outcome under low-light conditions. The order of
light conditions. We could not associate a negative impact on the SADs was changed randomly per the study protocol, so
placement success and times using NVG and SADs together to the effect of precedence should minimally influence the study
maintain a patent airway and deliver sufficient ventilation to results.
a manikin.
Conclusions
We believe these results could be replicated in live patients. To
verify this hypothesis, further investigations will need to be This pilot study on the use of various SADs in combination
performed. with NVG shows that extraglottic insertion to maintain a

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