Columns, Patient Care

Blind Insertion or Blindly Inserted: Advanced Airways Revisited

Issue 2 and Volume 43.

Blind insertion or blindly inserted?

One thing we do in EMS that many of us most pride ourselves on is advanced airway management—though gaining that pride may have required a few moments of pants-wetting terror along the way.

For patients in respiratory failure rapidly progressing to respiratory or cardiac arrest, there are few scenarios that run us right up against the front lines of life and death, and with so much potential to affect the outcome.

These cases bring into focus the cognitive (knowledge), psychomotor (manual), and affective (emotional/psychological) elements of our job like nothing else we do. Yet evidence keeps piling up about how much of a mess we often find ourselves in while managing them.

Skill Burn-In & Maintenance

Initial skill “burn-in,” for one, is inadequate. Only five live intubations are required for national certification. For perspective, emergency medicine residents and nurse anesthetists need at least 35 and 200 tubes, respectively, for certification and, in both cases, these are placed in the controlled and supervised environment of an ED or operating room.1 A 1998 study demonstrated that anesthesiology residents must place more than 50 tubes under direct supervision before they can achieve a success rate of 90%.2

Somehow, though, after those first five tubes and several years’ fewer training, paramedics are miraculously supposed to hit the mark on their knees, in dark rooms, intubating morbidly obese patients with full stomachs and upper GI bleeds, surrounded by upset family members, barking dogs and screaming children.

We also get a C-minus grade for skills maintenance. There are exactly zero requirements for demonstrating intubation or other advanced airway proficiency for national recertification, and with the increased number of advanced-level practitioners providing our communities with a “higher” level of care, we’re effectively diluting the advanced skills of practitioners by increasing the number of providers performing them.

A 2003 study of prehospital advanced level airway interventions in Pennsylvania showed that almost 40% of personnel performed no intubations in the space of a year, and more than two-thirds had placed two or fewer tubes.3 Which of these thousands of EMS personnel would you want to show up at your mom’s house when she’s in pulmonary edema?

We also have little to go on in terms of objective verification of tube placement. Some studies have demonstrated not only a significant rate of misplaced endotracheal tubes but, even worse, that these go unrecognized in almost 25% of cases—the highest rates occurring in the absence of continuous end-tidal carbon dioxide (EtCO2) monitoring capability.4,5

A blind solution

Armed with this knowledge and the more recent understanding that endotracheal intubation leads to increased pauses and decreased time-on-the-chest in cardiac arrest, we did what we often do in EMS: We closed our eyes, threw a solution at the problem, and hoped for the best. In this case, we adopted the widespread use of blind insertion supraglottic airway (SGA) devices.

Problem solved, case closed. Unfortunately, though, no one checked to see what happens with these devices in real cases of respiratory failure and cardiac arrest.

A recent study looked at more than 300 consecutive King SGA placements, comparing subjective success recorded on the patient care report (PCR), with objective verification of tube placement on the uploaded capnography waveform. They found that tubes had been misplaced in almost 20% of cases, and that more than 14% went unrecognized, reflecting a situation not much different from what we already knew about endotracheal tubes.6

By the way, this doesn’t mean there’s anything wrong with either the tube or the person putting one in. What it does mean is that we probably shouldn’t be placing them in the absence of EtCO2 monitoring capability. It also means that we must have the necessary quality assurance processes in place, as well as the software, personnel, and buy-in to ensure that EtCO2 isn’t only being used, but that it’s being used correctly.

Paramedicine 2050

Once again, we find ourselves taking a fresh look inside the “box,” including a recently proposed name change from EMS to Paramedicine, and the development of a white paper charting a new course for EMS by 2050.

What if we took just one thing, though, and set our sights on accomplishing it before the next name change or white paper? What if we set a requirement for continuous EtCO2 monitoring capability, as well as transparent, accountable QA processes to go with it? How many lives would we save? How much respect would we gain? How proud would we feel to get it right every time?


1. Accreditation Council for Graduate Medical Education. (2017.) Emergency medicine defined key index procedure minimums: Review committee for emergency medicine. ACGME. Retrieved Jan. 2, 2018, from

2. Konrad C, Schüpfer G, Wietlisbach M, et al. Learning manual skills in anesthesiology: Is there a recommended number of cases for anesthetic procedures? Anesth Analg. 1998;86(3):635–639.

3. Wang HE, Kupas DF, Hostler D, et al. Procedural experience with out-of-hospital endotracheal administration. Crit Care Med. 2005;33(8):1718–1721.

4. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med. 2002;37(1):32–37.

5. Silvestri S, Ralls GA, Krauss B, et al. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system. Ann Emerg Med.2005;45(5):497–503

6. Vithalani VD, Vlk S, et al. Unrecognized failed airway management using a supraglottic airway device. Resuscitation. 2017;119:1–4.