Airway Clearance Using Suction Devices in Prehospital Combat Casualty Care: A Systematic Review

Abstract

Airway management is at the forefront for combat medics dealing with battlefield trauma. For military service members, compromised airways are the second leading cause of potentially survivable death on the battlefield, accounting for one in ten preventable combat deaths. Effective suction is a critical component of airway clearance. However, currently available devices are too heavy and bulky to be carried by combat medics and are insufficiently powered. The industry has not responded to the need, with companies continuing to produce models using 1970s technology. A literature review was completed with the assistance of a librarian. The databases searched included: Biomedical Research Database (BRD), Computer Retrieval of Information of Scientific Projects (CRISP), Federal Research in Progress (FEDRIP), Defense Technical Information Center (DTIC), Pub Med/Medline, and OVID. Additionally, a Google Scholar search was performed to identify nonstandard sources. After screening, a total of 40 articles were used. There were no randomized controlled trials or other high-quality evidence that addressed the issues; there was limited peer-reviewed literature on the use, effectiveness, adverse effects, and safety of suction for use in combat casualty care. A review of the available literature revealed no standards, either proposed, validated, or accepted, for the safety or avoidance of adverse effects for portable suction device use in combat casualty care. Similarly, there are no accepted standards to guide the safe use and anticipated adverse effects of suction for use in prehospital combat or emergency care. Nevertheless, there are meaningful data that can be extracted from the few studies available combined with non-clinical studies, narrative reviews and case reports, and expert opinions.

Portable Medical Suction and Aspirator Devices: Are the Design and Performance Standards Relevant?

“…An extensive survey of first responders suggests that powered suction devices are simply too heavy to be carried in the combat medic’s aid kit [ 1 , 19 , 20 ]. In comparison with battery operated suction devices, manual suction devices typically weigh far less but are unable to provide effective, reliable suction during emergency or combat situations.…”

“…None of the current commercial portable suction devices employ a sensor to actively monitor device performance [ 19 ]. In addition, most commercially available portable suction devices specify changing and disposal of the canister between uses, but do not include the pump and primary housing.…”

“…Unfortunately, many of these commercial portable suction devices have not been scientifically validated for key performance measures relevant to prehospital care, let alone tactical combat casualty care [ 1 , 17 , 18 ]. Feedback from first responders, both civilian and military, described the major deficiencies of current commercial devices is that they are either too large and heavy to carry to the scene of an emergency (for powered systems) or too weak to effectively move viscous liquids (for manually operated systems) [ 1 , 19 , 20 ]. As combat medics are allowed discretion in which devices to include in their carry kits, this leads to elective exclusion of portable suction devices [ 21 ].…”

“…Figure 1 show some of the commercially available manually operated or battery powered suction units specifically advertised for use in prehospital tactical environments [ 20 ]. Most suction devices advertised for use in prehospital tactical environments were well within the specifications dictated by the ISO 10079-1 standards, yet no device on the market meets even the most basic field requirements on size, weight, and suction performance [ 1 , 19 ]. “Standards are the building blocks that provide for repeatable processes and composition of different technological solutions to achieve a robust end result.” [ 26 ].…”

A Market Review of Available Airway Suction Technology

“…1,2 Airway difficulties are typically caused by gross damage to the airway, traumatic shock, brain injuries, or impairment of other airway reflexes. 3 Compromised airways and/or head trauma often require the employment of airway management strategies, which typically include endotracheal intubation, cricothyroidotomy, supraglottic airways, and tracheostomy. 4,5 Blackburn, et al reported that prehospital endotracheal intubation was performed in 68% of patients that received an airway intervention in the prehospital combat setting, with nearly 25% having a combat medic as the highest level of provider recorded in the patient record.…”