Athletic Training and Sports Health Care

Original Research 

Airway Emergencies in Lacrosse: Impact of Exposure Procedure and Device on Time and Ventilation Quality

Richard J. Boergers, PhD, ATC; Thomas G. Bowman, PhD, ATC; Monica Lininger, PhD, ATC; Lacy Picinich, MS, ATC; Peter Bruno, MS, ATC; Corey Forlenza, MS, ATC; Gabriella Prata, MS, ATC

Abstract

Purpose:

To assess the impact of an airway exposure procedure and an airway management device to provide quality ventilations quickly on a simulation manikin wearing lacrosse equipment.

Methods:

Sixteen athletic trainers (8 men, 8 women; age = 35.6 ± 10.04 years) performed 1 minute of rescue breathing on a simulation manikin wearing lacrosse equipment under four conditions. The independent variables were airway exposure procedure (facemask removal [FMR], helmet removal [HR]), and airway management device (pocket mask [PM], King LT-D Airway [KA] [King Systems Corporation]). Placement success of airway management device (%), ventilation rate (breaths/min), volume (mL), volume in range (%), time to airway exposure (s), time to airway management device placement (s), and time to first breath (s) were measured.

Results:

Athletic trainers had 100% successful placement of both the PM and the KA. There was a significant interaction between airway exposure procedure and airway management device on mean ventilation rate and mean ventilation volume (F2,14 = 4.34, P = .034). Each univariate test also had a significant interaction (mean ventilation rate: F1,15 = 4.582, P = .049; mean ventilation volume: F1,15 = 8.044, P = .013). There was a significant pairwise comparison (P = .023), suggesting a higher mean ventilation volume when using the KA (462.19 ± 71.79 mL) compared to the PM (386.44 ± 142.11 mL) during FMR. There were significant main effects for airway exposure procedure (F1,15 = 37.95, P < .0001) and airway management device (F1,15 = 42.93, P < .0001) on mean time to first breath, showing HR to be faster.

Conclusions:

HR is the most time-efficient airway exposure procedure. If there is a suspected cervical spine injury, FMR with the chinstrap fastened and the KA provides greater ventilation volume.

[Athletic Training & Sports Health Care. 20XX;X(X):XX–XX.]

Abstract

Purpose:

To assess the impact of an airway exposure procedure and an airway management device to provide quality ventilations quickly on a simulation manikin wearing lacrosse equipment.

Methods:

Sixteen athletic trainers (8 men, 8 women; age = 35.6 ± 10.04 years) performed 1 minute of rescue breathing on a simulation manikin wearing lacrosse equipment under four conditions. The independent variables were airway exposure procedure (facemask removal [FMR], helmet removal [HR]), and airway management device (pocket mask [PM], King LT-D Airway [KA] [King Systems Corporation]). Placement success of airway management device (%), ventilation rate (breaths/min), volume (mL), volume in range (%), time to airway exposure (s), time to airway management device placement (s), and time to first breath (s) were measured.

Results:

Athletic trainers had 100% successful placement of both the PM and the KA. There was a significant interaction between airway exposure procedure and airway management device on mean ventilation rate and mean ventilation volume (F2,14 = 4.34, P = .034). Each univariate test also had a significant interaction (mean ventilation rate: F1,15 = 4.582, P = .049; mean ventilation volume: F1,15 = 8.044, P = .013). There was a significant pairwise comparison (P = .023), suggesting a higher mean ventilation volume when using the KA (462.19 ± 71.79 mL) compared to the PM (386.44 ± 142.11 mL) during FMR. There were significant main effects for airway exposure procedure (F1,15 = 37.95, P < .0001) and airway management device (F1,15 = 42.93, P < .0001) on mean time to first breath, showing HR to be faster.

Conclusions:

HR is the most time-efficient airway exposure procedure. If there is a suspected cervical spine injury, FMR with the chinstrap fastened and the KA provides greater ventilation volume.

[Athletic Training & Sports Health Care. 20XX;X(X):XX–XX.]

Lacrosse is a high-velocity sport that has been gaining popularity throughout the past two decades, expanding at both the high school and collegiate levels.1 According to the 2015 participation survey by U.S. Lacrosse, the National Federation of State High School Association has reported a growth rate of 29.5% for boy's lacrosse from 2010 to 2015.2 Additionally, at the collegiate level, there was a 33.6% growth rate from 2010 to 2015 in men's lacrosse participation, with an increase between 4.4% and 6.1% each year.2 Injuries to the head and neck are somewhat rare,3 but the consequences may be severe when they do occur.4 Equipment-intensive sports such as men's lacrosse require players to wear a helmet with a face-mask, which may interfere with athletic trainers' and other first responders' ability to expediently access a patient's airway during an on-field emergency. Multiple practice guidelines recommend high priority for providing spinal motion restriction and circulation, airway, and breathing during acute management of the spine-injured athlete.5,6

In an effort to improve patient outcomes, it has been recommended that all equipment be removed on-field prior to transport.7 However, a recent study on athletic trainers' emergency management practices for equipment-intensive sports found that athletic trainers often were the only health care provider present at practices and would require the assistance of emergency medical services personnel to assist with equipment removal.8 Therefore, many respondents indicated that they did not intend to remove equipment prior to transport due to a lack of trained personnel on-site for most events.8 In these cases, clinicians indicated they would remove the facemask and leave the helmet and remaining equipment in place while providing emergency care.8 There is evidence suggesting that facemask removal (FMR) of lacrosse helmets can be performed expediently9–11; however, once the airway is exposed, making a seal with a pocket mask (PM) has been shown to be difficult and did not allow for quality ventilations.12–14 Further complicating the choice of airway exposure procedure is the fact that lacrosse helmet removal (HR) has been found to have greater head and neck movement compared to FMR when performed by two rescuers.15 Recent studies have found the King LT-D Airway (KA) (King Systems Corporation), a supraglottic airway management device, useful for providing quality ventilations after FMR has been performed while leaving the chinstrap fastened,12,13 as well as in simulated difficult airways.16 In the event of suspected on-field spine injury, it is important for athletic trainers to know which combination of airway exposure procedure and airway management device will be most expedient, while producing high-quality ventilations.

The purpose of our study was to assess the impact of two different airway exposure procedures and two different airway management devices on the ability to successfully place the airway device for ventilation and provide quality ventilation on simulation manikins. Based on previous investigations, we expected the KA to provide higher-quality ventilations than the PM,12,13 especially when the facemask was removed with the chinstrap left in place. Secondarily, we evaluated the impact of the airway exposure procedure and airway management device on time to placement of airway management device and time to first breath. We believed that HR would be more expedient than FMR for providing access to the airway.15 Finally, we assessed the rating of perceived difficulty (RPD) of each of the airway management devices and the ability of athletic trainers to successfully use them. We expected the KA to be the easiest to use and predicted a high success rate based on results of previous studies.16,17

Methods

We used a 2 × 2 repeated-measures design to determine the effects of airway exposure procedure (HR or FMR) and airway management device (KA or PM) on successful placement of the airway device (%), ventilation rate (breaths/min), ventilation volume (mL), and volume in range (%) (American Heart Association [AHA] recommended 400 to 700 mL)18 during rescue breathing. We operationally defined success as using the device correctly according to manufacturer guidelines and having the ability to provide a minimum of 10 mL of oxygen during the first ventilation to the Laerdal Q-CPR high-fidelity manikin (Laerdal Medical), which triggers the SimPad (tablet device that records Q-CPR activities) to initiate data collection. Although the use of a PM is routine for an athletic trainer due to CPR retraining as a requirement for maintenance of certification, the use of a KA is a skill that requires additional practice to ensure correct placement. To be successful, the correct size must be chosen, placement in the airway must be correct, and inflation of the cuffs must occur followed by delivering adequate respiration volume. Our secondary aims were to measure time to airway exposure (s), time to placement of airway management device (s), and time to first breath (s) to determine the most timely airway exposure procedure and airway management device both alone and in conjunction with each level of the independent variables. Finally, we measured the participants' RPD with each level of the independent variables after each trial. The institutional review board at Seton Hall University approved this study prior to participant recruitment.

Participants

We recruited 16 athletic trainers (8 men, 8 women: age = 35.6 ± 10.04 years). All athletic trainers are trained in emergency cardiac care and must maintain professional rescuer-level CPR for their credential. All participants self-reported that they were free from any diagnosed skeletal, muscular, cardiovascular, or neurological conditions that may have interfered with their ability to kneel and perform rescue breathing. They signed the informed consent form and then completed a questionnaire regarding their previous experience performing the two airway exposure procedures and using the two airway management devices. Fourteen (87.5%) participants reported having practiced removing a lacrosse helmet at least once, with 3 of 16 (18.8%) reporting annual practice. Thirteen (81.25%) reported practicing lacrosse helmet FMR at least once, with 3 of 16 (18.8%) reporting they practiced annually. All participants (16 of 16, 100%) reported practicing annually with the PM. Ten (62.5%) reported having practiced making a seal with the PM over a chin-strap after a facemask was removed. Three (18.8%) reported having received formal training on the use of the KA in their athletic training curriculums. Eight (50%) of our participants had never used a KA. Only 3 (18.8%) of our participants reported practicing insertion of the device and practiced providing ventilations. After completing the questionnaire, participants moved on to an orientation session.

Instruments

We used a Laerdal Q-CPR high-fidelity manikin to measure and record ventilation rate, ventilation volume, and percentage of ventilations in the range of AHA guidelines. Q-CPR manikins have been found to provide reliable measures on compression and ventilation data related to quality CPR.19 We used an iPhone (Apple, Inc) stopwatch to measure time to airway exposure, time to placement of airway management device(s), and time to first breath. The manikin was properly outfitted with a new Warrior Evo helmet and chinstrap and new Warrior Burn shoulder pads (Warrior, Inc) as per manufacturer guidelines. We chose this helmet and shoulder pad because they are relatively popular among lacrosse athletes and are representative of what many athletes wear. We used a Dewalt DW920K-2 7.2V cordless 0.635 cm two-position cordless screwdriver (Dewalt) to perform screw removal during the FMR trials. Finally, we used two airway management devices: the King LT-D Airway and the pocket mask airway (size 4) (Laerdal Medical). We chose the PM rather than a bag valve mask because the student research assistant playing the role of the second rescuer had to stabilize the neck in our scenario, and having a single rescuer operate a bag valve mask results in inadequate ventilation volume.20 We chose the KA because the teaching of the use of adjunct airways is included in Standard 70 of the 2020 Commission on Accreditation of Athletic Training Education (CAATE) standards,21 and athletic trainer proficiency of these devices is included in the BOC Practice Analysis, 7th ed.22,23Figure 1 depicts the two airway management devices and Figure 2 shows the manikin set up for the trials.

Airway management devices. (Left) Pocket mask airway (Laerdal Medical) and (right) King LT-D Airway (King Systems Corporation).

Figure 1.

Airway management devices. (Left) Pocket mask airway (Laerdal Medical) and (right) King LT-D Airway (King Systems Corporation).

High-fidelity manikin with placement of airway access and airway management devices.

Figure 2.

High-fidelity manikin with placement of airway access and airway management devices.

Data Collection Procedure

Orientation Session. Participants completed an orientation session that averaged 20 minutes. Participants watched three instructional videos: (1) detailed one-person rescue breathing technique according to the 2015 AHA guidelines18; (2) detailed use of the KA; and (3) detailed steps for FMR and HR. After watching the videos, participants were shown the characteristics (including screw placement) of the Warrior Evo helmet. Participants then completed one practice trial of each of the airway exposure procedures (FMR and HR) and each of the ventilation devices (PM and KA) on the Laerdal Q-CPR manikin. Following practice trials, participants were given a 5-minute rest before the data collection session began.

Data Collection Session. Participants completed four different counterbalanced data collection conditions based on airway exposure procedure (HR or FMR) and airway management device (KA or PM) to limit learning and fatigue effects. The Laerdal Q-CPR manikin was outfitted with a new Warrior Evo helmet and chinstrap and new Warrior Burn shoulder pads according to the manufacturer recommended fit. The necessary airway devices and other necessary equipment were easily accessible for the participants during all trials. The cordless screwdriver and the towel to place under the head of the manikin during HR were placed to the right of the participants as they knelt at the head of the manikin. A water-based lubricating spray (Airway Lubricant; Laerdal Medical), a PM, and two different sizes of the KA were placed to the left of the participant. The same research assistant (male; 25 years; 83.9 kg; 1.68 m) assumed the role of a second rescuer for all trials. He maintained cervical spine stabilization on the manikin to the left of the participant for each trial, making sure to leave enough room to access the lateral screws during FMR. He followed the guidelines for bilateral mastoid cupping illustrated in the 2016 U.S. Lacrosse Facemask and Helmet Removal Guidelines.24 He placed a hand around each mastoid process and was positioned to the left side of the manikin while using his forearms against the chest as a counterforce. Figure 3 depicts the research assistant and participant interacting with the manikin during a trial.

A participant performing facemask removal and pocket mask airway ventilations with the student research assistant maintaining in-line cervical stabilization with the bilateral mastoid cupping technique.

Figure 3.

A participant performing facemask removal and pocket mask airway ventilations with the student research assistant maintaining in-line cervical stabilization with the bilateral mastoid cupping technique.

To begin a trial, researchers placed the manikin into a condition of pulse and no breathing, and announced: “You have completed your initial assessment, the patient is unresponsive, is not breathing, but does have a pulse. Cervical spine injury cannot be ruled out at this point.” Timing began when both of the participants' hands contacted the helmet during HR, or when they picked up the cordless screwdriver for FMR trials. For the HR procedure, participants were made aware of the sizing/locking system on the posterior aspect of the helmet, making the helmet tighter on the occiput region. While kneeling superior to the head of the manikin, participants removed the chinstrap by un-snapping all four snaps on the helmet because a previous study showed this method caused less motion in the cervical spine compared to cutting.25 They then were required to remove the helmet with a slight forward tilt/rotation. Once the helmet was removed, a towel was placed under the posterior head to minimize movement and promote neutral cervical spine stabilization.26 Time to airway exposure was defined as the time from when the participant first touched the helmet until the towel was placed underneath the head of the manikin. For FMR, the participants also knelt superior to the head of the manikin, and then used the cordless screwdriver to remove three screws on the helmet while making sure to keep the T-nuts on the inside of the helmet shell from spinning. Once the screws were removed, the participant removed the facemask from the helmet, and time to airway exposure ended when the face-mask was placed on the floor. Helmets were rebuilt after all FMR trials. Members of the research team inspected all hardware to ensure proper functioning and the screws were fastened with a uniform torque of 5 Nm10 using a PTD5 torque wrench (Park Tools). Screws and T-nuts were only replaced if there was wear noticed at the time of inspection. Time to placement of airway management device began at the end of time to airway exposure and continued until the first breath was delivered with the airway management device.

During the airway management portion of the trials, participants placed the PM over the nose and mouth of the manikin, and used the thumb and index finger to create a seal, while the other fingers pulled the jaw upward to provide ventilation. Time to first breath was noted when the participants placed their mouth on the PM and began their first rescue breath. For KA insertion, the participants were required to select the proper sized KA for the size of the manikin (size 4 airway indicated for patients 1.52 to 1.83 m tall). The KA was then sprayed with a water-based lubricant covering the tube, and the KA was inserted into the open mouth by placing the tube in the corner of the mouth, rotating the tube laterally, and then medially rotating the KA after insertion until it was in line with the mid-line of the mouth. The participants then connected the syringe to the valve, inflated the cuffs to 70 mL as per manufacturer instructions, and disconnected the syringe to begin rescue breathing. Time to first breath ended once the participants placed their mouth on the valve and began providing the first rescue breath.

One minute of rescue breathing was performed following the first breath and the participants' performance on ventilation rate, volume, and percentage of volume in range was recorded by the SimPad device. At the end of each trial, the participants completed a RPD to describe their experience during each trial. The RPD consisted of a 5-point Likert scale (range = 1 to 5, 1 = very easy, 5 = very difficult). A 3-minute rest period was given after each trial before moving to the next trial. The methods were repeated until all four potential combinations of the independent variables were completed.

Statistical Analysis

We conducted an a priori sample size estimation using G*Power 3.1.9.2 software.27 We used the means and standard deviations of the ventilation volume data between the PM airway and KA from a previous study on airway management to calculate effect sizes.13 Recommended sample size was calculated using the actual effect size with alpha levels set at 0.05 and statistical power set at 0.8. For a repeated measures design, using a multivariate analysis of variance to answer the primary aim, with an anticipated effect size of 1.66, a sample size of 8 would be needed to detect a significant difference, if one truly existed. We were not able to perform a power analysis for time data because no prior study has compared the time of these two airway management devices. We chose a sample size of 16, which exceeded our suggested sample size for our main hypothesis and allowed for easy counterbalancing.

A total of 64 trials were performed (four trials by each of the 16 participants). Data were analyzed using SPSS software (version 25.0; IBM Corporation). All alpha levels were set to 0.05 for all analyses except for Bonferroni post-hoc adjustments. Airway management device placement success rate was determined by dividing the number of trials where at least 10 mL of air entered the lungs of the manikin on the first attempt by the total number of trials. To analyze the impact of the independent variables on the ventilation quality, a repeated-measures multivariate analysis of variance (RM MANOVA) was used because of the statistically significant relationship (r = 0.58) between the two dependent variables of ventilation volume (mL) and ventilation rate (breaths/min). The independent variables included airway exposure procedure (HR and FMR) along with airway management device (KA and PM). Following significant relationships, univariate analytic procedures were conducted. Effect sizes were reported as partial omega squared (ωp2).

We then used separate 2 × 2 within-subjects analyses of variance (RM ANOVA) to examine interactive and main effects between airway exposure procedure (HR and FMR) and airway management device (KA and PM) on the following dependent variables: time to airway exposure (s), time to placement of airway management device (s), and time to first breath (s). Prior to all analyses, we inspected the data for sphericity, normality, and linearity.

Given that the RPD data were ordinal in nature, we used nonparametric analyses (Wilcoxon signed rank tests) to determine differences. With these nonpara-metric analyses, the independent variables were analyzed separately. These same analytic procedures were followed for volume within range due to the use of a percentage as the dependent variable.

Results

All 16 participants had successful first time placement in both of their KA trials (32 of 32; 100%) and provided at least 10 mL of air to the manikin during the first ventilation attempt. Additionally, all trials using the PM (32 of 32; 100%) were successful at providing the 10 mL of air to the manikin. Descriptive results for continuous variables are located in Table 1 and categorical variables are found in Table 2.

Descriptive Statistics (Mean ± Standard Deviation) for Continuous Outcome Variables

Table 1:

Descriptive Statistics (Mean ± Standard Deviation) for Continuous Outcome Variables

Descriptive Statistics (Median [Range]) for Categorical Outcome Variables

Table 2:

Descriptive Statistics (Median [Range]) for Categorical Outcome Variables

Ventilation Quality

We observed a significant interactive effect of airway exposure procedure and airway management device on mean ventilation rate and mean ventilation volume (F2,14 = 4.34, P = .034, ωp2 = 0.28). Each univariate test also had a significant interaction (mean ventilation rate: F1,15 = 4.582, P = .049, ωp2 = 0.17 and mean ventilation volume: F1,15 = 8.044, P = .013, ωp2 = 0.2V B9). The only statistically significant pairwise (P = .023) comparison suggested a higher mean ventilation volume when using the KA (462.19 ± 71.79 mL) compared to the PM (386.44 ± 142.11 mL) during the FMR procedure. All other post-hoc tests were non-significant (P > .05).

There were no significant differences on percent of volume within range for either the airway exposure procedures (chi-square1 = −0.904, P = .366) or the selection of the airway management device (chi-square1 = −1.461, P = .144).

Expediency

Statistical results for expediency can be found in Table 3. We observed no interactive effects of airway exposure procedure and airway management device on mean time to airway exposure (F1,15 = 1.19, P = .29, ωp2 = 0.01), mean time to airway management device placement (F1,15 = 0.07, P = .79, ωp2 = −0.057), or mean time to first breath (F1,15 = 0.59, P = .46, ωp2 = −0.02). However, there was a significant main effect for airway exposure procedure (F1,15 = 54.40, P < .0001, ωp2 = 0.75) on mean time to airway exposure, indicating that HR (19.18 ± 10.96 seconds) was faster than FMR (31.28 ± 11.54 seconds). Additionally, there was a significant main effect for airway management device on mean time to airway management device placement (F1,15 = 50.08, P < .0001,D ωp2 = 0.74), indicating that the PM (16.88 ± 5.79 seconds) was faster than the KA (39.52 ± 10.61 seconds). There were significant main effects for airway exposure procedure (F1,15 = 37.95, P < .0001, ωp2 = 0.68) and airway management device (F1,15 = 42.93, P < .0001, ωp2 = 0.71) on mean time to first breath. For the main effect of airway exposure, HR was significantly faster (46.99 ± 14.55 seconds) than FMR (59.89 ± 15.39 seconds), just as was seen with mean time to airway exposure. The PM (43.01 ± 1X3.00 seconds) was significantly faster than the KA (63.87 ± 16.94 seconds).

Comparison of Univariate Continuous Outcome Measures

Table 3:

Comparison of Univariate Continuous Outcome Measures

Difficulty of Procedure

We noted a difference in RPD scores (chi-square1 = −3.906, P < .001) for type of device, with the PM being significantly more difficult to use than the KA. FMR was also statistically more difficult when compared to HR (chi-square1 = −2.279, P = .023). Medians and ranges are presented in Table 2.

Discussion

This is the first study to our knowledge to evaluate the ability of athletic trainers to successfully place and use a KA. All previous studies that compared the KA to other airways in simulated lacrosse patients had the device placed by members of the research team.12,13 Participants in our study learned to select the correct size KA, properly insert it, correctly inflate the cuffs, and then adequately ventilate the manikin. The first time placement success of the KA by the athletic trainers (100%) was similar to what was reported by other health care providers.16,17,28,29 In a study29 comparing urban basic life support first responders using the KA with paramedic-initiated endotracheal intubation, the responders using the KA had a greater first attempt success rate of 87.8% in comparison to the endotracheal intubation success rate of 57.6%, illustrating the efficacy of the KA by other health care providers with the same level of basic life support certification as athletic trainers. Another study found that emergency medical technician basic participants had a 100% success rate in placing the KA in a simulation manikin.16

Our participants took a slightly longer time to place the device than what is reported in other studies.16,17 It took our participants nearly 40 seconds to insert and inflate the cuffs, whereas various studies of emergency medical services personnel report between 18.417 and 22.516 seconds for insertion of the KA into a simulation manikin. Some of this additional time can be accounted for in that our participants were kneeling and had to deal with a helmeted manikin, and we included the first breath into this procedure so the participants also needed to retrieve and place the mouthpiece on the KA and breathe. Participants in the other studies were standing with the manikin head at waist level and did not use the spray lubricant, which can be a time-consuming step. Further, our participants were novices, which may have required additional time compared to participants in previous studies who were familiar with the KA.16,17 A study of residents inserting a laryngeal mask airway (a supraglottic airway similar to the KA) into a manikin wearing a football helmet reported a median time to placement of 19 seconds in experienced participants and 35 seconds in novice.28 Because our participants had a 100% success rate in placing and using this device in our study, we believe that, with minimal training, athletic trainers have the capability to use this airway management device in an on- or off-field emergency with similar success rates as other health care professionals. We believe that with further training, athletic trainers will be able to place the KA more rapidly.

In FMR trials, the PM resulted in lower-quality ventilations (rate, volume, and percent in range) than the KA. In addition to the statistically significant differences that were present, it should be noted that these also represented clinically meaningful differences, because the FMR and PM ventilation volume fell below the AHA recommended range. The AHA guidelines recommend a ventilation volume between 400 and 700 mL and a rate of one breath every 6 seconds when using an advanced airway.18 The complexity of the combination of FMR and PM is further identified by the highest RPD by the participants. Both the PM and KA devices achieved near identical results in terms of ventilation quality in the HR trials. Our results demonstrated that the helmet chinstrap interferes with the ability to make a seal on the face with the PM and yields low-quality ventilations. After FMR, the KA is able to provide high-quality ventilations because no seal around the mouth and nose is necessary.

Our data parallel the findings of other studies that suggested the chinstrap interferes with the ability to provide quality ventilations using a PM in lacrosse helmets12–14 and football helmets.30,31 Removing the chin strap would decrease the ability of the helmet to stabilize the head of a patient with a suspected cervical spine injury, thereby increasing the risk of iatrogenic injury.32 Therefore, based on these previous studies,12–14,30–32 HR might be required if the only airway management device available requires a seal on the face to provide ventilations with adequate cervical spine stabilization. Although we support the recommendation that protective equipment should be removed prior to transport,7 an adequate number of trained personnel may not be available to perform protective equipment removal.8 During this specific situation, initial airway management performing FMR may be as prudent an approach as leaving a well-fit helmet in place, performing FMR, and providing rescue breathing with a KA should limit cervical spine motion, maintain a neutral spine alignment,33 and provide adequate ventilation volume based on our findings. However, the decision on whether or not to remove the helmet should always be informed by uniform standards and under physician-directed practice protocols.

The KA, a supraglottic airway, is an alternative airway management device that eliminates the need to create a seal over the chinstrap because it can easily be placed within the airway with the chinstrap intact and untouched. The KA has also been shown to create the largest ventilation volumes when ventilating a simulation manikin wearing a lacrosse helmet with the facemask removed in comparison to other airway management devices including the bag valve mask, the oral-pharyngeal airway, and the nasopharyngeal airway.12,13

The most expedient combination of airway exposure procedure and airway management device was HR and PM. The HR trials were faster than FMR trials for mean time to airway exposure and mean time to first breath. The PM had faster mean time to first breath than the KA regardless of airway exposure technique, which can be attributed to the fact that the KA requires time to insert and inflate the cuffs. Performing HR with the PM is the most expedient (97.75 ± 12.00 s), whereas FMR with KA requires the most time (132.29 ± 17.03 s). These data suggest that it takes longer to expose the airway with FMR and that using the KA also adds to the total time.

The use of supraglottic airway management devices such as the KA is included in the CAATE Educational Standards21 and Board of Certification Practice Analysis,22 but their use is still emerging in athletic training clinical practice due to knowledge34 and practice gaps. According to Tan and Sedory,35 “Most states consider blindly inserted airways as basic life support devices and thus will allow the AT to deploy extraglottic airways” (p. 267). We encourage clinicians to familiarize themselves with their state practice acts to ensure their ability to use these devices. We also encourage clinicians to seek out continuing education courses on the use of airway management devices such as the KA and to practice extensively prior to using in clinical practice.

Limitations and Future Research

This work was an important step in studying the ability of athletic trainers to provide expedient rescue breaths at a high quality using different airway exposure procedures and airway management devices. A primary limitation was that this study was conducted in a controlled laboratory setting, on a hard surface and in a situation of low salience. Study participants interacted with a high-fidelity manikin, which may not have similar characteristics to a human patient (saliva, skin, oil, etc). We cannot ensure that these results would translate to real-life emergencies, with higher stakes and less controlled settings. We also do not know the impact that these results would have on the survival of a patient. It should be noted that the use of supraglottic airway devices carry the risk of complications such as regurgitation and aspiration of gastric contents, compression of vascular structures, trauma, and nerve injury, but are rare when used correctly.36 We did not control for the previous experience of our participants and acknowledge that could have affected the outcomes. Another limitation would be that we only studied one brand of helmet with a standard chinstrap that was provided with the helmet from the manufacturer in new condition, which may affect the generalizability of our data.

We recommend that researchers study other airway adjuncts such as the laryngeal mask airway and combitube. It would also be interesting to compare athletic trainers to other health care providers. We also recommend motion analysis of head/neck movement between the two devices (PM and KA). We suggest studying other helmet models to improve generalizability. Finally, future studies should also investigate the ability of clinicians to measure oxygen saturation levels of patients and apply supplemental oxygen when using airway adjuncts.

Implications for Clinical Practice

Due to the necessity of swift care for patients in respiratory distress, HR is indicated as the most time-efficient procedure to expose the airway. If the helmet is removed, the most expedient airway management device that should be used is the PM because high-quality ventilations can occur when there is no interference by the chinstrap during attempted rescue breathing. However, if there is a suspected cervical spine injury, the procedure that may be clinically indicated based on several factors is FMR to expose the airway. When the chinstrap is left in place to aid in head stabilization, the KA will provide breaths with sufficient volume according to the AHA 400- to 700-mL volume standard with the greatest amount of ease. FMR with KA ventilations was rated as the easiest of the four trials.

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Descriptive Statistics (Mean ± Standard Deviation) for Continuous Outcome Variables

VariableFacemask RemovalHelmet Removal


Pocket MaskKing AirwayPocket MaskKing Airway
Time to airway exposure (s)32.85 ± 13.5929.70 ± 9.4919.37 ± 9.4818.99 ± 12.14
Time to airway management device placement (s)17.16 ± 6.3740.05 ± 11.9816.6 ± 5.2138.98 ± 9.23
Time to first breath (s)50.01 ± 14.5269.76 ± 16.2636.00 ± 11.4757.98 ± 17.62
Rate (breaths/min)10.88 ± 5.1613.19 ± 2.9312.69 ± 2.1212.44 ± 2.20
Volume (mL)386.44 ± 142.12462.19 ± 71.79443.88 ± 93.39444.63 ± 66.35

Descriptive Statistics (Median [Range]) for Categorical Outcome Variables

ParameterFacemask RemovalHelmet Removal


Pocket MaskKing AirwayPocket MaskKing Airway
Volume in range (%)83 (0 to 100)100 (7 to 100)96 (0 to 100)88 (0 to 100)
Rating of perceived difficulty4 (1 to 5)2 (1 to 3)2 (1 to 4)2 (1 to 3)

Comparison of Univariate Continuous Outcome Measures

Outcome MeasureInteractionAirway Access Procedure Main EffectAirway Management Device Main Effect



F1,15PPower (1-β)F1,15PPower (1-β)F1,15PPower (1-β)
Time to airway exposure (s)1.19.290.1854.40.010.992.45.140.31
Time to airway placement (s)0.07.790.060.53.480.1150.08.010.99
Time to first breath (s)0.59.460.1137.95.010.9942.93.010.99
Authors

From Seton Hall University, South Orange, New Jersey (RJB); University of Lynchburg, Lynchburg, Virginia (TGB); Northern Arizona University, Flagstaff, Arizona (ML); Kapiolani Bone and Joint Center, Honolulu, Hawaii (LP); Zimmer Biomet, Philadelphia, Pennsylvania (PB); Roxbury High School, Roxbury, New Jersey (CF); and Danbury High School, Danbury, Connecticut (GP).

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Richard J. Boergers, PhD, ATC, 400 South Orange Avenue, South Orange, NJ 07079. Email: Richard.boergers@shu.edu

Received: March 02, 2020
Accepted: September 23, 2020
Posted Online: February 17, 2021

10.3928/19425864-20201116-02

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