Airway Management: The Equipment and Technique Debate Continues

Kenny Navarro // July 31, 2015

If polled, it is reasonable to expect EMS personnel to rank advanced airway management as one of the most important prehospital interventions. Despite this attitude, numerous studies and case reports highlight the complications associated with advanced airway management, especially when inexperienced providers attempt to perform endotracheal intubation1-4. The American Heart Association acknowledges the lack of adequate evidence to recommend a specific advanced airway or to recommend the optimal timing for device insertion relative to other advanced procedures5.

Airway error types

Researchers recently proposed a classification system for errors and complications created when attempting to use an advanced airway6. This system includes technical errors, cognitive errors, and adverse anatomic effects.

Technical errors associated with advanced airway placement include airway misplacement7, multiple failed attempts8, prolonged attempts9, and accidental dislodgement after correct placement10. Technical errors may decrease ventilation effectiveness11 and increase the frequency and duration of interruptions in chest compressions during a resuscitation attempt12.

Cognitive errors deal with the knowledge needed to perform a skill. EMS personnel must know the advantages and disadvantages of each of the different type of advanced airway devices, and well as the indication for use. Examples of cognitive errors in advanced airway management include patient assessment errors, failure to troubleshoot airway problems, and overcompensation for oxygenation and ventilation deficiencies. Overcompensation, in the form of hyperventilation is common in traumatic brain injury management[13] and during resuscitation attempts following cardiac arrest that occurs both in the out-of-hospital[14] and in-hospital settings15-17.

Post - ROSC arterial hyperoxia (a potential consequence of overcompensation) has also been shown to decrease survival to hospital discharge rates in adult patients who suffered cardiac arrest18. Although arterial hyperoxia increases oxygen content of the blood, it also reduces regional perfusion through vasoconstriction19. The net effect is decreased oxygen delivery to the organs and tissues.

The final category of errors and complications are those that produce anatomic abnormalities. For example, esophageal-tracheal tube insertion can result in tracheal injury, upper airway bleeding, tongue edema, or esophageal laceration or perforation20. Overinflation of the laryngeal tube cuffs can cause swelling in the tongue significant enough to produce life-threatening airway obstruction21. Complications related to the endotracheal intubation involving anatomic abnormalities include tongue perforation22 and tracheal laceration23,24.

Although trauma related to the use of endotracheal tube introducers is rare, most complications result from railroading, whereby the healthcare provider aggressively and forcefully pushes the endotracheal tube over the bougie even after meeting resistance25. Use of the bougie has resulted in bronchial laceration26, pharyngeal wall perforation27, bleeding and blood clot formation in a mainstem bronchus28, and tracheal perforation resulting in a complete intratracheal airway obstruction29.

Using the most appropriate device

Despite the problems associated with advanced airway placement, EMS personnel can improve patient ventilation by inserting a supraglottic airway when compared to ventilation with a bag-mask even when the EMS provider has only limited training in advanced airway management30. A recent investigation demonstrated that early insertion of a supraglottic airway significantly improved chest compression fraction when compared to bag-mask ventilation in patients who suffered an out-of-hospital cardiac arrest31. This study did not measure survival outcomes however; other studies have demonstrated improvements in clinical outcomes with higher chest compression fractions32-34. The increase in chest compression fraction observed in the study is likely due to the change in compression/ventilation ratios that followed advanced airway insertion.

KISS principle applies

EMS providers should strive to keep things simple when deciding which airway device to use in a specific situation. Specifically for the paramedic practitioner, the airway toolbox is filled with a multitude of devices and procedures for establishing and maintaining airway patency. Paramedics should consider the following:

  • the anatomic presentation of the airway
  • the environment in which the patient presents
  • the confidence of their ability to perform the procedure reliably and accurately
  • the ability of the device or procedure to preserve airway patency, and
  • the potential for complications and untoward outcomes with the device

In general, the simpler the device or procedure, the greater the reliability and accuracy of its use. However, not all anatomic presentations or environmental conditions are conducive to simpler devices. EMS providers should be not only well versed in how to use every device and procedure available, but also to critically decide when to use the appropriate method and what other choices need to be used in case of failure.

Current and future studies

Researchers in France are currently investigating whether the use of an endotracheal tube improves 28-day survival with favorable neurological outcome following out-of-hospital cardiac arrest compared to use of bag-mask ventilation35. The study is expected to conclude mid-year 2017.

Researchers in the United Kingdom are studying out-of-hospital cardiac arrest and comparing outcomes between 9,000 adult patients whose airways were managed with an endotracheal tube and those managed with a second generation supraglottic airway36. The primary outcome for the study, known as the UK AIRWAYS-2 study, is neurological outcome (as measured by the modified Rankin scale) at hospital discharge. Enrollment began early this year and is expected to conclude in late 2017.

Later this year, the Resuscitation Outcomes Consortium will begin enrolling patients into the Pragmatic Airway Resuscitation Trial (PART [ Identifier: NCT02419573]). For adult patients who develop cardiac arrest in the out-of-hospital environment, researchers will randomly allocate those patients to receive early advanced airway management with either an endotracheal tube or laryngeal tube37. The primary outcome for the study will be 72-hour survival. By the time the study concludes in late 2020, the researchers expect to enroll 3,000 patients.


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2. Gausche, M., Lewis, R. J., Stratton, S. J., Haynes, B. E., Gunter, C. S., Goodrich, S. M., Poore, P. D., McCollough, M. D., Henderson, D. P., Pratt, F. D., & Seidel, J. S. (2000). Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: A controlled clinical trial. Journal of the American Medical Association, 283(6), 783–790. doi:10.1001/jama.283.6.783

3. Katz, S. H., & Falk, J. L. (2001). Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Annals of Emergency Medicine, 37(1), 32–37. doi:10.1067/mem.2001.112098

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5. Neumar, R. W., Otto, C. W., Link, M. S., Kronick, S. L., Shuster, M., Callaway, C. W., Kudenchuk, P. J., Ornato, J. P., McNally, B., Silvers, S. M., Passman, R. S., White, R. D., Hess, E. P., Tang, W., Davis, D., Sinz, E., & Morrison, L. J. (2010). Part 8: Adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122[suppl 3], S729–S767. doi:10.1161/CIRCULATIONAHA.110.970988

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7. Jones, J. H., Murphy, M. P., Dickson, R. L., Somerville, G. G., & Brizendine, E. J. (2004). Emergency physician-verified out-of-hospital intubation: Miss rates by paramedics. Academic Emergency Medicine, 11(6), 707–709. doi:10.1197/j.aem.2003.12.026

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11. Davis, D. P., Hoyt, D. B., Ochs, M., Fortlage, D., Holbrook, T., Marshall, L. K., & Rosen, P. (2003). The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. Journal of Trauma, 54(3), 444-453. doi:10.1097/01.TA.0000053396.02126.CD

12. Wang, H. E., Simeone, S. J., Weaver, M. D., & Callaway, C. W. (2009). Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation. Annals of Emergency Medicine, 54(5), 645-652. doi:10.1016/j.annemergmed.2009.05.024

13. Davis, D. P., Dunford, J. V., Ochs, M., Park, K., & Hoyt, D. B. (2004). The use of quantitative end-tidal capnometry to avoid inadvertent severe hyperventilation in patients with head injury after paramedic rapid sequence intubation. Journal of Trauma, 56(4), 808-814. doi:10.1097/01.TA.0000100217.05066.87

14. Aufderheide, T. P., Sigurdsson, G., Pirrallo, R. G., Yannopoulos, D., McKnite, S., von Briesen, C., Sparks, C. W., Conrad, C. J., Provo, T. A., & Lurie, K. G. (2004). Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation, 109(16), 1960-1965. doi:10.1161/01.CIR.0000126594.79136.61)

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16. Losert, H., Sterz, F., Köhler, K., Sodeck, G., Fleischhackl, R., Eisenburger, P., Kliegel, A., Herkner, H., Myklebust, H., Nysaether, J., & Laggner, A. N. (2006). Quality of cardiopulmonary resuscitation among highly trained staff in an emergency department setting. Archives of Internal Medicine, 166(21), 2375-2380. doi:10.1001/archinte.166.21.2375

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30. Roth, D., Hafner, C., Aufmesser, W., Hudabiunigg, K., Wutti, C., Herkner, H., & Schreiber, W. (2015). Safety and feasibility of the laryngeal tube when used by EMTs during out-of-hospital cardiac arrest. American Journal of Emergency Medicine, 33(8), 1050-1055. doi:10.1016/j.ajem.2015.04.048

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