Airway Fundamentals

Prehospital emergency medicine is fluid. Our profession changes as new research is published, new equipment hits the market and new procedures are approved. From the practitioner’s standpoint, these advances can be costly, confusing, and even distracting, taking us further from the basic principles that served as the foundation of our training. For educators, the influx of new information and adjuncts increases the challenges faced in the classroom.”ž

In primary emergency care education, we focus on teaching core competencies so our graduates can function as entry-level EMTs and paramedics. In continuing education, our focus shifts to the retraining of existing providers on core principles as well as introducing new technology and updated standards and guidelines.

Quality improvement standards dictate that we search out methods to render care in a more effective and efficient manner, and ensure that a superior standard of care is achieved. The issue of technology’s role in prehospital airway management begins with its past and continues into the present, which includes the issues we currently face, how to Ë™get back to basicsÓ and how to add new technologies such as rapid sequence intubation (RSI) and other airway adjuncts.

Where It All Began
In the late 1970s, EMS was in its infancy, especially compared with where it is today. Many procedures and equipment we utilize today were not yet in existence. For example, pulse oximetry, portable blood glucose meters, transcutaneous pacing and 12-lead ECG technology weren’t available to the prehospital provider.

Although we all have different recollections of our own start in EMS, my early memories in”žEMS include key changes in airway management. In 1977, I began my EMS career with Flushing Community Volunteer Ambulance Corp. in”žQueens,”žN.Y. Four response units graced our bayÆ’1974 and 1975 Cadillac ambulances, a converted Suburban and a brand-new Type I Chevy modular. As you glanced inside of each unit, you noticed a “Hudson Emergency LIFESAVER Kit” proudly displayed (see photos, p. 70). This airway kit featured a clear plastic display box with a set of oropharyngeal airways (OPA) in order by size in a foam base. The problem was that we used an airway, washed it and then set it back in the foam enclosure, ready to be reused on another unconscious patient.

The pride and joy of the service with regard to airway management was the E&J Resuscitator. It weighed in at 35 lbs., had a steel frame that held two steel “D” tanks, and functioned as an O-powered suction unit, positive-pressure ventilator and oxygen source.

Another device we proudly carried was the HOPE II Resuscitator, a bag-valve mask (BVM) that was not disposable like most devices at that time. It consisted of a black, self-inflating bag assembly, and the mask was made of hard rubber material.

Oxygen masks in the late 1970s, such as the rubber mask manufactured by HUDSON, were neither disposable nor transparent. In addition to the obvious hazard of cross-contamination of patients, emergency personnel could not see when their patient exhaled air or began to vomit.

A novel product used in the old days of EMS was the Oral Screw. The Oral Screw was a threaded device, usually packaged with an adult OPA in a clear plastic box. Predominately used to maintain an open position to facilitate suctioning or OPA placement, it was put between the teeth on one side of the mouth and twisted in place like an ordinary screw. The problem with the Oral Screw was that if it was used on a patient with a central nervous system injury who had their teeth clinched shut, exerting pressure on one side of a patient’s jaw put unnecessary pressure on the opposite jaw’s hinge joint.

In the early days of CPR training, education and certification took place using an air- or foam-filled Resusci Anne that had a series of lights that activated when you compressed at the right depth and ventilated appropriately. If your compressions were too shallow or too deep, a red light activated. A paper printout that exited out the side of the “patient” was also produced. It could then be used to evaluate each person’s performance. The tape showed the depth of each compression as well as the effectiveness of every ventilation. The printout also allowed you to see the time that lapsed between crew changes during CPR sequences.

The first breaths given for CPR at that time were “four stair-stepped” ventilations. Each breath was given in rapid succession without letting the air escape between breaths. These ventilations looked like a staircase on the printout graph.

The services providing ALS care had limited advanced airway equipment. In many areas, the only available adjunct was the esophageal obturator airway (EOA). The EOA remained the primary prehospital airway management device used until the late ’80s, when endotracheal intubation (ETI) became more predominant on a national level.

Other Basic Airway Skills
Although manual airway maneuvers and basic airway adjuncts, such as the modified jaw thrust maneuver and oropharyngeal airway, are taught as part of the EMT curriculum, these skills are often neglected in actual practice and performed incorrectly. The first skills reassessed when EMTs enter paramedic training are their BLS skills. This is often very enlightening for the students and their instructors.

To minimize unpleasant surprises, training officers should review basic skills with employees for compliance to all levels of the EMT curriculum. This should include reviewing indications, contraindications and procedures for all airway skills and adjuncts, no matter how elementary.

First responders, EMTs and paramedics should exhibit that they are competent in the use of bag-valve mask resuscitators, suction devices and other airway adjuncts. Crews should be regularly evaluated, re-trained and tested because providers at all levels periodically develop bad habits and use the devices inappropriately. Some common mistakes include:”ž

ÃŽHaving an incorrect facemask seal;

ÃŽFailing to perform a manual airway maneuver while attempting ventilations;

ÃŽVentilating with too much volume or too rapidly;

ÃŽFailing to use a Sellick maneuver when appropriate;

ÃŽNeglecting to watch for adequate chest rise during ventilations;

ÃŽFailing to adequately secure or monitor endotracheal tube placement after it’s initially placed and”ž”ž confirmed; and

ÃŽAllowing attempts at advanced procedures to override correctly performed BLS procedures to maintain adequate ventilations.

BLS airway control is an imperative part of the prehospital environment. In order to be proficient at any skill, repetitive practice sessions and diligence on the part of the training officers is paramount.

Hypoxia isn’t always caused only by the failure to intubate. Rather, it’s often the result of a failure to properly ventilate the patient. A patient benefits a great deal more from being ventilated correctly with a BVM and an OPA than being subjected to numerous failed attempts to use an advanced airway device, which results in significant periods without adequate ventilation. This must be emphasized to your staff in training as well as in your protocols.

Improving Intubation Rates
ETI remains the most common and efficacious method of maintaining a patent airway. However, this skill requires frequent practice to keep providers competent and comfortable with performing it.

Prehospital intubation success rates are shockingly low in parts of the country. Many factors can contribute to these high failure rates, including inadequate training, inexperience, apathy and poor technique.

One problem surfacing throughout the United States is that, as”žEMS systems increase the total number of paramedics deployed on a multitude of vehicles responding to the same incidents, fewer opportunities arise for paramedics to perform intubations. This can result in skill deterioration.

We’re usually products of how we were taught. To improve prehospital intubation success rates, it’s imperative that EMS educators cover procedures such as ETI in a repetitive fashion. It’s also helpful to use training aids that are as realistic as possible. Consider purchasing several different types of airway simulators. Having several different types of training devices gives students the ability to practice on seemingly different anatomies. Students will increase their flexibility in adapting the skill to a particular patient and not vice versa. Although the basic procedure being taught remains the same, the student will notice an improvement in their confidence and efficiency with the skill.”ž

Many intubation failures are the result of inexperience. It’s now common for some paramedics to work in areas where they may only get one or two opportunities a year to perform an intubation. Conversely, an individual may be employed in a busier jurisdiction in which three or four paramedics respond to calls requiring intubation, thus increasing the observation of ETI, but not the actual opportunity to perform the skill.

Your organization can combat this problem in a number of ways. First, increase the number of required intubation practice sessions. This will help the provider feel more comfortable with the skill as it should be performed.

Second, have your department training division staff contact local hospitals to secure intubation rotations in the operating room (OR). OR time is a golden opportunity for a prehospital provider to hone their skills on patients in a controlled environment. Although no hospital rotation can mimic the often-chaotic environment in the field, it’s the best live practice available.

Paralytics in Airway Management
The use of pharmaceutical agents in airway management in the field is now commonplace. Many systems nationwide have RSI or pharmacologically assisted intubation (PAI) protocols. Which agents are used and who actually administers them varies depending on jurisdiction.

In general, an induction agent with amnesic properties, such as etomidate or a standard benzodiazepine (diazepam, lorazapam, or midozalam), is used initially to sedate the patient. Then a short-acting neuromuscular blocker is used to induce paralysis so the patient can be successfully intubated.

Succinylcholine (Anectine), which is a depolarizing neuromuscular blocking agent, is often the agent of choice. Its primary effects last four to six minutes. Some departments with extended transport times now use vecuronium (Norcuron) and pancuronium (Pavulon). These agents are non-depolarizing neuromuscular blockers, and their effects are longer than that of succinylcholine by more than 30 minutes. Typically, these agents are used after succinylcholine and after confirmation of tube placement.

Prior to advancing to the use of pharmacological agents to assist in intubation, it’s essential that all personnel involved in the procedure are well trained and comfortable not only with the agents to be used, but in their own ability to perform basic and advanced airway skills. By using paralytics, we effectually remove the patient’s ability to respire and, therefore, become solely responsible for their airway.”ž

Most systems require their providers to attend an advanced airway class prior to being able to participate in the RSI program. These classes review basic airway principles as well as allow students to practice for difficult intubations. A well structured presentation also includes pharmacological interventions and related indications, contraindications, dosages and side effects as well as scenario-based practice attempts.

Integrating New Technology
Today, many prehospital airway management devices are available. Commercial cricothyrotomy kits, specialized laryngoscope blades and devices, CPAP and automatic transport ventilators are some of the airway devices considered luxury items for the typical field provider.

One category of luxurious but beneficial items is audio/visual aids. Some AV training aids, such as AirwayCam, document exactly what a provider sees while attempting intubation. These training aids are made possible through the use of fiber optic pinhead cameras placed at the distal end of a laryngoscope, which is then used during live intubations. The resulting video gives a better understanding of exactly what to expect and what the landmarks can actually look like. Programs such as this are usually relatively expensive but well worth the money.

These devices have specific uses and require additional training, which may make them cost-prohibitive. When considering the purchase of such supplemental items, departments should consider the following questions:”ž

ÃŽWill the “rank and file” staff utilize the device, or will only supervisors or specialized teams use it?

ÃŽWhat will the final cost of the purchase be after adding training, re-training and maintenance costs?

ÃŽWhat determining factor led to the purchase? Is a particular problem being addressed or corrected by the purchase, or is it just adding to the arsenal of devices your system already has in place?

ÃŽWhat is the expected frequency for its use and how will it change patient outcomes?

ÃŽIs the training program effective enough to allow the provider to feel comfortable using the device in a high-pressure situation?

ÃŽWhat are the perceived disadvantages of the device, and how will you (or can you) overcome them?

ÃŽWill the provider become too reliant on the device?

After you’ve discussed and considered each of the above items, you’re prepared to decide if the device in question is right for your agency.

As providers and educators, we’re flooded with new technology, research, devices and statistics. Each year new procedures are introduced and equipment is being upgraded. This can be time consuming for students and training staff and costly for your agency. In addition to the cost of initially purchasing a new adjunct, it’s also necessary to consider the cost involved in properly training and educating your staff. The cost of initial training and continuing education often dwarfs the purchase price of an item. However, you must keep in mind the potential liability your agency will have if your staff uses a device inappropriately.

What other steps can we take to improve our airway maintenance skills? Train regularly and consistently. Start with the basics taught during your standard CPR classes and move forward. Select the best individuals possible to lead your training efforts. They should be technically competent and have powerful leadership qualities.

Also, vary the types of training sessions you offer and make them as interesting as possible. Make sure all providers know your expectations as well as the fact that they will be evaluated during the educational activity. If budgets allow, utilize a variety of training aids and remember that leadership comes from the top down. Top management must stand behind all educational endeavors. This includes funding. If management and the training staff don’t seem interested, your providers won’t be either.

Franc Ferola, BA, EMT-P, LP, is a paramedic and managing partner of U.S. Public Safety Solutions LLC, a consulting and education provider based in”žFlorida and”žTexas. Additionally, he serves as the director of operations/EMS coordinator at Health Career Institute in”žLake Worth,”žFla.


1. Roberts JR, Hedges J.Clinical Procedures in Emergency Medicine,Philadelphia: W.B. Saunders Co.; 1985.

2. Wang HE. “Failed Prehospital Intubations: An Analysis of Emergency Dept. Courses and Outcomes”. Prehospital Emergency Care 2001;5:134-141.”ž

3. Wang HE. “Predictors of Failed Prehospital Endotracheal Intubation. Academy of Emergency Medicine 2003;10:717-724.”ž

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