Advanced Airway Management – Should Paramedics Be Intubating?

It’s a shame that so little attention was paid to the 2003 ACLS Reference Textbook and Experienced Provider Manual.

2003 AHA EPPart of the problem was the delayed release. By the time it finally came out, everyone knew the 2005 update was around the corner. In my opinion, it was the best set of ACLS books the AHA has ever published. One of the best things about the ACLS Reference Textbook is Chapter 8 – Airway, Airway Adjuncts, Oxygenation, and Ventilation. I wish it was required reading for every paramedic in the United States. It would save a lot of breath, because we spend entirely too much time rehashing the same ground in the debate about prehospital tracheal intubation.

Here are some highlights:

The ECC Guidelines 2000 emphasize the need for training of healthcare providers in bag-mask ventilation […] This emphasis on use of bag-mask ventilation should reduce the perceived need for urgent insertion of advanced airways […] Bag-mask ventilation can prevent the potential deleterious consequences of attempted intubation by inexperienced providers and complications of undetected tube misplacement or displacement […] The emphasis on bag-mask ventilation is particularly useful for caregivers working in out-of-hospital settings where opportunities for experience in intubation are extremely limited. This emphasis is especially appropriate when transport times are short (Class IIa).

Tracheal intubation, once the “gold standard” of assisted ventilation, remains the advanced airway of choice only for experienced providers working in programs with careful performance monitoring, defined requirements for skills maintenance (e.g., establishment of minimal number of intubations to be accomplished per year), and an atmosphere of continuing quality improvement […] In the absence of quality improvement programs, the probability of lethal complications from tracheal intubation become unacceptably high.

Seems pretty straightforward to me.

  • Does your EMS system observe careful performance monitoring?
  • Do you QA/QI every intubation attempt?
  • Is there a defined requirement for skills maintenance?
  • Do you rotate through the OR or cadaver lab if necessary?
  • Are you working in an atmosphere of continuing quality improvement?

If so, then you are in that minority of paramedics that has any business attempting tracheal intubation in the prehospital setting.

Unfortunately, there is still a tremendous amount of denial on the part of paramedics in EMS systems all over the country. I’m not talking about King County Medic One, Boston EMS, Hennepin County EMS, Wake County EMS, or any of the other EMS systems that meet the above captioned criteria. I’m talking about the ones that don’t.

I frequently reference a survey conducted with program directors of CAAHEP-accredited paramedic programs during a 7-month period. The survey showed:

  • 60.7% were having difficulty obtaining live tracheal intubations in their respective affiliated hospitals
  • 48.6% of the programs required 5 live intubations prior to graduation
  • 28% of the programs required 10 or more (still not enough)
  • 83.5% of program directors said that every student should have performed at least 1 successful live patient intubation

I doubt anyone would argue that this is adequate. If our paramedic students are not coming out of school with proficiency in tracheal intubation then it’s up to each individual system to ensure safe and competent practice. It’s not enough to claim that paramedics are proficient at tracheal intubation. It must be demonstrated. We should also be able to demonstrate that patients do better with tracheal intubation than without it. Unfortunately, most of the available evidence suggests the opposite.

Should paramedics be intubating? “It depends!”

Here is a small excerpt from the 2015 AHA ECC Guidelines (the entire evidence summary is worth reading).

Recommendations for advanced airway placement presume that the provider has the initial training and skills as well as the ongoing experience to insert the airway and verify proper position with minimal interruption in chest compressions. Bag-mask ventilation also requires skill and proficiency. The choice of bag-mask device versus advanced airway insertion, then, will be determined by the skill and experience of the provider.

There is a big difference between “skill dilution” and “never had the skill in the first place”.

Further reading

How to Master Tracheal Intubation at ACLS Medical Training

Airway Management with Rich Levitan, M.D. at EMCrit

Randomized Trials of Prehospital Endotracheal Intubation in Cardiac Arrest at JEMS

How Many Intubations Does It Take To Become Competent?

Updated 03/19/2017

1 Comment

  • mark says:

    Great article. Like any ALS skill they should be practiced regularly. Intubation is still the gold standard of airway care but as you point out practice makes perfect. The next best thing to intuibating people is simulation where a range of situations can be mimicked. Having to confirm placement with etCO2 and remove if cannot be confirmed and having a failed intubation drill has reduced many complications and should be the standard process with every service.

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