If you’re an EMS provider preparing to intubate, you know a few things about your situation. One, your patient is in dangerous shape, with an airway that’s compromised or in imminent peril. Two, other methods of airway management have failed or aren’t viable, necessitating an invasive option that can be difficult even under pristine circumstances. And three, you’d better get it right the first time.
That’s a troubling trifecta of challenges to face. Intubation in the field has higher rates of complication and failure than in the hospital,1 and requiring more than one attempt to place an endotracheal tube can have negative consequences for your patient.2–5
What makes this important intervention so difficult, and what can providers do to accomplish it more easily and successfully?
THE FIELD CAN BE UNFORGIVING
Whether you work in a hospital or the field, many of the factors that make endotracheal intubation and its preceding step, laryngoscopy, difficult are the same.
Among patients that can include age, size, physical status, anatomy and hemodynamic stability. Prehospital providers may also have to contend with questions of access, location, positioning and illumination.
Among providers, factors can include training, technique, experience, skill and knowledge. They can also be bound by differences in devices, techniques and medications.
“There are several red flags that can potentially alert both anesthesia and EMS providers that an airway may be difficult,” said Patrick Shay, a certified registered nurse anesthetist from Pennsylvania who’s also spent 36 years in EMS. “When we look at any patient for an anesthetic, a procedure or even an emergent intubation, we have to take a few seconds to actually look at their physical anatomy and evaluate those red flags.”
EMS providers of course have the popular LEMON mnemonic – representing look externally, evaluate (3-3-2 rule), Mallampati score, obstructed airway and neck mobility – to help predict difficult airways,6 as well as other methods.7 Beyond that, they may anticipate laryngoscopy difficulty when patients are obese, very young (with smaller airways) or old (with potential cervical spine changes), or have physical characteristics like short necks, facial hair, teeth and mouth problems or large tongues. Pregnancy can cause challenges too, especially late, as the growing baby displaces blood and tissue upward.
What you do when laryngoscopy/intubation proves resistant depends on your setting. In the hospital, you may have a highly trained anesthesia team available to assist.
“They’re the experts in any hospital,” said Shay, who works for North American Partners in Anesthesia at UPMC Community Osteopathic in Harrisburg, Pennsylvania. “Most hospitals have at least one anesthesia provider, often 24/7 for respiratory or cardiac arrest responses or any airway emergencies or intubations. We have an amazing array of medications and an armamentarium of management equipment at our disposal that’s not available to EMS. And while we’re trained to function as sole practitioners, we can always summon assistance.”
EMS, not so much. Often it’s just you and your partner out there on a figurative island. “You really need to learn how to be able to function on your own,” Shay added. “The field can be very unforgiving.”
PRACTICE MAKES PROFICIENCY
In both environments, managing the airway starts with a plan: How do caregivers expect to control it? Will basic measures be sufficient, or are advanced measures required? What factors will affect the process? Are all needed tools at hand and all players on the same page? And, vitally, what’s plan B if plan A fails?
For EMS those stakes are high. Not only does it lack the backup of hospital colleagues in critical situations, but its patients are often less stable – significantly sick or injured. If they’re dire enough to need intubation, their survival may rely on getting it right.
It’s no big secret that doing that starts with practice.
“I encourage EMS providers to use manikin or simulation training on a regular basis to improve their skill, technique, performance and skill retention,” said Shay. “It’s imperative that they feel comfortable with performing all those skills, whether it’s BVM ventilation or endotracheal intubation or needle or surgical cricothyrotomy. They need to be well trained and understand their devices.”
On scenes, take advantage of the resources you do have. Some services may have supervisors or second units available to assist in cases like difficult airways or advanced interventions, and BLS providers can be great assets as well in setting up, locating and handling equipment, and supporting and facilitating paramedic performance of the actual skills.
Shay suggests a mnemonic of “three Ps” to help optimize first-pass success: preparation, positioning and performance.
Preparation – Seconds may count in airway management, but taking a few at the outset to evaluate your patient’s particulars will save you more later. Do a quick visual assessment of the airway: Is there a foreign-body obstruction? Blood, vomit or mucus? Have equipment prepared in advance to perform suction and clear the playing field. Have laryngoscopes and stylets and tubes ready at hand.
“Consider every airway difficult,” Shay advised. “Build plans and backup plans that focus on airway management, not just intubation. Our goal may be successful intubation, but if for some reason we don’t like what we see, we have to be ready to back out, mask ventilate and proceed with a secondary plan.”
Positioning – Patient positioning is important but can be neglected. A blanket or pillow beneath the head achieves the correct “sniffing” position with the ears above the clavicle. Also elevate the stretcher head at least 10–15 degrees if possible – always intubate down, not up.
Performance – Use the best approach for best results: Work from the head, with the patient properly positioned and tools at hand. All providers should know the plan. Use well-practiced tools and techniques. “You want to be disciplined and controlled and focused – using what I like to call ‘airway zen,’” said Shay. “The three Ps are integral to that.”
Finally, EMS organizations have a responsibility here too. They must arm their providers with the right tools and technologies to help them achieve success.
Among those tools in 2024 is video laryngoscopy.
VIDEO LARYNGOSCOPY IMPROVES THE ODDS
The first video scopes made an immediate impact when they arrived a quarter century ago and have continued to advance since. There is little question across the recent scientific literature that they improve first-pass success.8–12
“The days of just doing direct laryngoscopy are over,” said Shay. “There are video laryngoscopy devices out there now that really give EMS providers that edge that is constantly available to anesthesia providers.”
Among those is the McGRATH MAC video laryngoscope from Medtronic. The company’s latest enhancements to the device help providers both experienced and novice achieve first-pass success faster and with fewer adverse events.
Featuring the Macintosh blade familiar to most providers and an ergonomic design to maximize user comfort, the McGRATH MAC provides line-of-sight video with improved optics, durability for the field and features to help monitor and preserve battery life. It supports clinician safety by allowing users to stand upright while intubating, reducing exposure to droplets and potential pathogens.
Shay saw an early version of the device at a nursing conference several years ago and liked it enough to approach Medtronic reps.
“I told them how much I loved the device, and if anyone needed it, it would be EMS – this is literally the perfect device for EMS,” he recalled. “It’s the closest thing to a traditional Macintosh direct laryngoscopy device, which is what every EMS and anesthesia provider originally trains on. And when we talk about best approaches and building technique, we always fall back on these original direct laryngoscopy techniques. The McGRATH MAC just feels natural in the hand of an experienced advanced airway management provider.”
Priced at a point affordable for EMS, it’s now the main video laryngoscope used across 14 anesthesia sites operated by Shay’s employer.
“All of our providers love it – it’s their go-to device,” he added. “I believe the thing sells itself.”
For more information, visit Medtronic.
REFERENCES
1. “EMS field intubation.” David M. Gnugnoli, Abhishek Singh, Katherine Shafer. StatPearls [Internet]. 2023. www.ncbi.nlm.nih.gov/books/NBK538221/
2. “Association between multiple intubation attempts and complications during emergency department airway management: A national emergency airway registry study.” Michael D. April, Steven G. Schauer, Dhimitri A. Nikolla, et al. American Journal of Emergency Medicine. November 2024. www.sciencedirect.com/science/article/abs/pii/S0735675724004558
3. Association between repeated tracheal intubation attempts and adverse events in children in the emergency department.” Hiraku Funakoshi, Yuri Kunitani, Tadahiro Goto, et al. Pediatric Emergency Care. February 2022. https://journals.lww.com/pec-online/abstract/2022/02000/association_between_repeated_tracheal_intubation.38.aspx
4. “Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department.” Edir S. Abid, Kelsey A. Miller, Michael C. Monuteaux, Joshua Nagler. Emergency Medicine Journal. 2022. https://emj.bmj.com/content/39/8/601.info
5. “The importance of first pass success when performing orotracheal intubation in the emergency department.” John C. Sakles, Stephen Chiu, Jarrod Mosier, et al. Academic Emergency Medicine. January 2013. www.ncbi.nlm.nih.gov/pmc/articles/PMC4530518/
6. “Difficult airway assessment acronym.” Anna Hernandez. Osmosis. June 2024. www.osmosis.org/answers/lemon-difficult-airway-assessment-acronym
7. “A comprehensive review of difficult airway management strategies for patient safety.” Hoon Jung. Anesthesia and Pain Medicine (Seoul). October 2023. www.ncbi.nlm.nih.gov/pmc/articles/PMC10635845/
8. “First-pass success of video laryngoscope compared with direct laryngoscope in intubations performed by residents in the emergency department.” Akihiko Sugaya, Keiko Naito, Tadahiro Goto, et al. Cureus. October 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10665768/
9. “Video versus direct laryngoscopy for tracheal intubation of critically ill adults.” Matthew E. Prekker, Brian E. Driver, Stacy A. Trent, et al. New England Journal of Medicine. June 2023. www.nejm.org/doi/full/10.1056/NEJMoa2301601
10. “The impact of video laryngoscopy on the first-pass success rate of prehospital endotracheal intubation in the Netherlands: a retrospective observational study.” Iscander Maissan, Esther van Lieshout, Timo de Jong, et al. European Journal of Trauma and Emergency Surgery. 2022. www.ncbi.nlm.nih.gov/pmc/articles/PMC9532291/
11. “Video laryngoscopy is associated with first-pass success in emergency department intubations for trauma patients: A propensity score matched analysis of the national emergency airway registry.” Stacy A. Trent, Amy H. Kaji, Jestin N. Carlson, et al. Annals of Emergency Medicine. December 2021. www.annemergmed.com/article/S0196-0644(21)00696-X/abstract
12. “First-pass success intubations using video laryngoscopy versus direct laryngoscopy: A retrospective prehospital ambulance service study.” Christopher M. Eberlein, Isidora S. Luther, Tom A. Carpenter, Luis D. Ramirez. Air Medical Journal. September–October 2019. https://pubmed.ncbi.nlm.nih.gov/31578974/
McGRATH MAC is a registered trademark of Medtronic.
