Columns, Patient Care

Endotracheal Intubation isn’t Always Necessary

Issue 8 and Volume 39.

Walking in the house, you smell the odor of alcohol and emesis—as you approach the patient it gets stronger. The beer cans, cups and munchies spewed about suggest there’s been a party. Dispatch sent you to care for an intoxicated person, but didn’t reveal the potentially critical nature of the situation.

The patient, a college-aged male, is lying face down in a pool of vomit. Random gurgling sounds are heard and the occasional bubble erupts through the emesis as he attempts to breathe. You and your partner move swiftly. There are no obvious signs of trauma, nor has a traumatic event been suggested by the bystanders. The patient is rolled to a supine position.

Using the patient’s shirt, which is lying next to him, your partner wipes away the majority of the vomit and moves the patient’s head to a head-tilt position. The patient’s respiratory effort increases, but remains inadequate. Using a hard tip suction catheter, some of the remaining secretions are evacuated from the patient’s mouth.

Your partner applies a bag-valve mask (BVM) and the patient’s chest rises. You hand the oxygen supply tubing from the BVM to the EMT student riding with you and ask her to attach the tubing to the oxygen tank and turn the gauge to 15 Lpm.

Your partner removes the mask and you slide the oral pharyngeal airway (OPA) into the oral cavity, slowly twisting it into place, but the patient begins to gag. You remove the OPA. Concerned about triggering more vomiting, your partner requests you place a nasal pharyngeal airway (NPA) instead. You measure the soft nasal device, apply a small amount of lubricant and, as your partner lifts the BVM, easily slip it into place without complication. Your partner continues to ventilate.

The patient’s pulse is strong at 96 bpm and his blood pressure is 130/90. A finger stick to evaluate his blood glucose level reads 110 mg/dL. His pulse oximetry reading is 99% with assisted ventilations. Police are on scene and confirm there was a party and the patient was found in his current condition by other party goers. Other than bystanders telling you the patient was “pretty wasted,” no other history is available.

As you prepare to transport, the EMT student asks if a supraglottic airway device should be placed or if an ALS unit should be called to place a “breathing tube.” You and your partner smile at each other and continue laying the patient on the stretcher. You tell the student the “breathing tube” is known as endotracheal (ET) intubation and the patient is being ventilated successfully, so they’re going to continue ventilation with the BVM and NPA in place, keeping suction close at hand, and transport BLS.

The patient is ventilated easily during transport, with good chest rise and a pulse oximetry reading of 98–100%. As you approach the hospital, the patient increases his responsiveness and is breathing more constantly on his own. Patient care is transferred to the receiving ED staff without incident. Looking at your student, you and your partner know there are questions to be answered.


Airway management is important. EMS providers must remember there’s no one-size-fits-all solution. In other words, not all patients with chest pain require high-flow oxygen, and not all unconscious patients require intubation any more than all lacerations require tourniquets. In-depth discussion of studies examining the risk and benefit of oxygen administration and advanced airway management such as supraglottic airways and intubation is beyond the scope of this article, but providers should understand that airway management and oxygen administration should be managed like other treatments.

Patients should be assessed and treated appropriately for their condition. Airways should be opened and cleared as necessary. The focus should then be on adequate ventilation and oxygenation.

The patient in this case had an obstructed airway that was cleared using a cloth and suction. These simple maneuvers allowed the patient to begin breathing more spontaneously, but still inadequately. EMS moved to assisting ventilations with a BVM. The appropriate adjunct was selected to help maintain a patent airway without causing other problems such as additional vomiting. If the patient continued to vomit, or if the bag mask didn’t provide adequate chest rise or maintain an adequate pulse oximetry reading, the providers would have to consider other options such as supraglottic airway placement or calling for an advanced provider to intubate the patient.

In this case, basic airway management techniques worked well. The point is that EMS must assure patients have a patent airway with an appropriate rate and depth of breathing. A variety of procedures and tools are available for EMS providers to obtain this goal, but remember one size doesn’t fit all.

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