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ALTERNATIVE AIRWAYS devices with gastric venting or access when possible. Where: EMS vs. ED, Etc. Alternative airways are popular in many EMS services and ORs. Elsewhere—for example, with code teams, ICUs and EDs—their use, while increasing, is still highly variable. In our experience, ED nurses and phy- sicians are often unfamiliar (and hence uncomfortable) with extraglottic devices that may have been placed prior to the patient's arrival. Many physicians instinc- tively pull the alternative airway and imme- diately try to place an endotracheal tube because they assume it provides superior airway management. Though well inten- tioned, prior to "pulling" the extraglottic device, one should first evaluate whether the airway device is working. If it is, don't mess with success! It is helpful to consider why the alterna- tive airway was placed. It's one thing if it was placed by a BLS crew that had no other option and isn't working well. Then, cer- tainly, pull it! But it's an altogether different scenario if it was placed by a senior para- medic after a failed intubation. In that case, as in so many others, if it's working, leave it! Of course you can imagine all sorts of scenarios that fall between those extremes, but in general, be reluctant to pull any air- way device that is successfully oxygenating, ventilating and providing protection against aspiration. 4,5 Rapid sequence airway is a recently described variant of rapid sequence intuba- tion being seen in emergent situations. RSA calls for the same medications and prepara- tions used for RSI, but instead of placing an endotracheal tube, you place an extraglot- tic airway—preferably one that allows for gastric suctioning. The advantages are clear, especially considering the amount of prac- tice required to maintain ETT intubation competency. When the patient arrives at the hospital and is stabilized, the extraglottic device can be carefully exchanged for an ET tube under controlled conditions. In many cases, the ET tube can be placed directly through the extraglottic airway, especially if a flexible fiber-optic/video scope or optical stylet is available. 6–8 When: LEMON, MOANS & RODS Situations that suggest airway management and/or breathing difficulties are good times to consider using alternative airways. We have found three simple mnemonics to help remember those situations and guide when to use (or not) extraglottic devices. LEMON The LEMON mnemonic can help the pre- hospital provider determine if an alterna- tive airway might simply be the airway of choice due to the likelihood of a difficult laryngoscopy. L—Look externally (long or short mandible, such as in Pierre Robin syndrome; high, arched palate; short "bull" neck; beard or mustache; large tongue; large incisors). E—Evaluate the 3-3-2 rule (three fingers of mouth opening, three fingers between mentum and hyoid, two fingers between the hyoid and thyroid cartilage). M—Mallampati (score of Class III or IV suggests higher risk of a difficult airway). O—Obstructions (conditions such as angioedema, epiglottitis, supraglottic swell- ing, smoke inhalation or trauma that lead to the inability to swallow secretions). N—Neck mobility (situations involving cervical spine immobilization or fixation, or rheumatoid arthritis, which impact neck mobility). 9 MOANS The MOANS mnemonic can help determine if placing an alternative airway device is the preferred choice due to factors that could lead to ineffective bag-mask ventilation. M—Mask seal (e.g., significant facial hair or facial trauma). O—Obesity/obstruction (inability to swallow secretions due to conditions such as angioedema, supraglottic swelling, smoke inhalation). A—Age greater than 55 (age-related decreased structural definition due to facial atrophy that leads to poor mask seal). N—No teeth (consider replacing dentures if available to achieve a better mask seal). S—Stiff lungs requiring increased ventila- tor pressures (asthma, COPD, ARDS, term pregnancy). 9 RODS The RODS mnemonic can help determine if the successful placement of a rescue airway may be compromised. In severe cases, the provider may consider a cricothyroidoto- my as the airway of choice if endotracheal intubation or placement of an extraglottic device is likely to be unsuccessful or inef- fective. R—Restricted mouth opening. O—Obstruction of the upper airway or larynx. D—Distorted or disrupted airway. S—Stiff lungs requiring increased ventila- tor pressures. 9 When: Cardiac Arrest and the Pig Study Studies on cardiac arrest outcomes with extraglottic airways vs. traditional endo- tracheal intubation report a mixed bag of results and have elements some consider to be inherently flawed. The Resuscitation Outcomes Consortium and AIRWAYS-2 studies focused on large, international multicenter trials to investi- gate this issue. Their findings suggest that if you are in an EMS system with plenty of experienced intubators who can intubate on the first attempt without interrupting CPR and still carry out all the critical ACLS interventions, then perhaps intubation will prove to be best. But in most of our systems, where manpower is limited and initial intu- bation success rates are less than 80%–90% even with stopping CPR, we suspect the patient is better off with an extraglottic airway. 10–18 As a result of a pig study, a concern was raised about alternative airways potentially THE MOANS MNEMONIC CAN HELP DETERMINE IF PLACING AN ALTERNATIVE AIRWAY DEVICE IS THE PREFERRED CHOICE. 40 OCTOBER 2015 | EMSWORLD.com