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Airway management has come under a lot of scrutiny within our industry over the past few years.
Should paramedics be intubating? Why not just use a supraglottic airway? Do we need to use a video laryngoscope? What does an intubation “attempt” really mean?
While each agency and region will continue to have their own protocols related to airway management, it’s time that we universally stand up as an industry to combat the demons that try to squash our ambitions toward successful airway management, whether that’s via endotracheal intubation or supraglottic airway use.
Here’s four tips to improve your airway management success.
1. Size-up and set-up for success
Some EMS providers brag about the intubation they performed in a dark alley, in an overturned car, in the middle of a snow storm by candlelight with only a tongue depressor, duct tape and a Hershey’s bar.
This MacGuyver-style of intubation isn’t something we should necessarily brag about. After all, it often shows we weren’t adequately prepared to begin with!
Now, before anyone throws something at me (or their screen), let me explain.
There’s a reason why the anesthesiologist comes into the room before a surgery and asks the patient to open wide, stick out their tongue, move their head around, smile to show their teeth, and looks at the patient’s jaw profile. It’s to size-up their patient.
This initial assessment helps to evaluate the patient’s Mallampati score, their LEMON score, their overall head and neck mobility and the likelihood of whether or not their patient will be categorized as a “difficult intubation.”
While I completely understand that our patients in EMS don’t typically plan their day around respiratory failure or cardiac arrest, it doesn’t mean that we can’t take a few seconds to perform a size-up assessment upon our arrival.
Size-ups provide us with the information we need to prepare for set-up.
If you’re anticipating intubation for your patient, then begin to pre-oxygenate them: 4-6 lpm via nasal cannula for a few minutes can go a long way!
Move your patient to an area where you have space to work. Don’t try to do this in a cramped bathroom; move your patient to the living room, or at least the hallway.
Get the patient into your “office” (ambulance) sooner, rather than later. Have access to all of your equipment and secured on your cot (which is adjustable, by the way). However, if they’re presenting in cardiac arrest, don’t move them. Work on scene.
Elevate the patient’s head and torso. When you think about airway alignment, lying on the floor and trying to intubate someone places providers in a truly difficult position in terms of lines of vision.
Again, I understand that our environment and situations don’t always allow us to have big and bright shining lights, four feet of space around the bed, and a platform that places the patient to our own waist or chest height, but nothing says that we shouldn’t strive to replicate this environment.
Place your equipment by your side. Verbalize what you’re doing and seeing. Set up for success, all while being prepared for difficulties.
2. Pre-plan for plan B
I hope that plan B doesn’t equate to performing a cricothyrotomy in your mind; there are certainly a number of options that we should attempt before getting to this point!
During your size-up and set-up phase, anticipate any difficulties that you might encounter by being ready for an unsuccessful attempt (and on that topic, talk with your administration and medical director to define the term “attempt”).
- Suction: check.
- Bougie: check.
- Bigger tube, smaller tube: check.
- Different blade: check.
- Supraglottic airway: check.
Identify potential problems, then plan out their solutions.
Problem: Anterior airway
Solution: Assign someone to apply cricoid pressure
Problem: Airway secretions
Solution: Position the suctioning device on your right side for easier access
Problem: Unable to manipulate your endotracheal tube with a stylet
Solution: Have a bougie readily available
Pre-plan your plan B, ward off the bad spirits and plan for success, all while anticipating and being prepared to tackle difficulties.
3. Practice often
Practice every month, or even every shift. My “intubation challenge” to you is to take a tally of your available mannequins, create a list of different positions and situations, utilize different devices, and map-out a different intubation scenario for each week on every shift.
Even with supraglottic devices, prepare yourself by practicing often. Intubation and advanced airway management are a very low-frequency (but high-acuity) event within our scope of practice. So, rather than complaining that “we just don’t intubate very often anymore,” force your hand by practicing as often as you can. The more that you can see the simple, see the difficult, work through challenges, and prove your comfort and competency through practice, the higher the chance of success when you actually face the scenarios in a real situation.
4. Single-technique mastery
Truly understanding how the anatomy looks within the oropharynx, what the purpose of your 4-Mac or 3-Miller laryngoscope blades are, and how your supraglottic airway sits within the upper airway are all ways to promote skill mastery.
While I certainly encourage practicing with a number of different devices in the classroom setting, I wholeheartedly advocate for starting with a single-technique when you’re actually face-to-face with your patient.
That means that if your agency uses a particular brand of a video laryngoscope device, then you need to practice on that device until you know it inside-and-out. You need to be intimately comfortable with how to use it, what its strengths are, what its weaknesses are, and when you’ve reached your limits and need to move on to plan B (which you should already have accounted for).
Personally, my “weapon of choice” is a 4-Mac. I use it on everyone, regardless of their age or size, every time. I know how far to insert it, how to manipulate it, how to move both a stylet and a bougie around it ... and I know when it’s time to move on to plan B.
How do I know this? Through lots of practice (and actual patient use).
I’ve succeeded with it. I’ve failed with it. I’ve positioned myself differently while using it. I’ve positioned the patient differently while using it. This is my laryngoscope. There are many others like it, but this one is mine.
Every provider, every situation and every patient are going to be different. At the end of the day, however, it all comes down to practice, preparation and, ultimately, perfection. We can only accomplish these components if we tackle this skill as a professional – as a master – and with a plan for success in place.
