How to Practice and Improve Advanced Airway Management

Arthur Hsieh // June 30, 2014

Managing an emergency airway accurately requires a combination of competencies, including excellent motor skills and thoughtful clinical decision-making. This is especially true in endotracheal intubation (ETI), where a sterile endotracheal tube must be directly inserted into the trachea.

While the benefit of ETI is currently being debated, it is considered an essential skill for paramedics and may be the airway intervention of choice, when other options are insufficient.

Practice makes perfect

Reliable ETI requires proper technique and experience. Unfortunately, the ability to practice and gain such experience is limited. Paramedic providers rarely have the opportunity to intubate1. In addition, the number of "live intubations" a paramedic may acquire during the initial education process may be minimal; one student performance database reports an average of one live attempt per paramedic student2. Finally, the number of alternative airway devices that require less training to perform than ETI reduces the frequency of intubation.

It's clear that training on this seldom-used, but highly critical skill is absolutely essential to maintain competency. There are several ways to make sure that the training provides maximum effect for acquisition and retention.

Where to practice

Initial airway education has traditionally used a combination of lecture and group practice to help students acquire the skill. It may be helpful but limited in perfecting the skill3. It is essential that the initial training is followed by repetitive practice, under increasing realistic conditions.

For example, after students practice with the intubation head on a table, move the head to the floor, where most patients will present. Over time, have the manikin on a gurney, on a bed — anywhere where real patients would be.

The equipment should also mimic real-world situations. Intubation tubes should be in their wrappers, and students should use sterile technique when practicing. A variety of tubes should be available, so that students can decide which size tube to use.

If the manikin's lungs are exposed, cover them with a light sheet or a shirt so that students observe chest rise, rather than the lungs inflating. Lung sounds should be auscultated with an actual stethoscope, so actual placement of the bell is performed.

Master precision

Highly technical procedures such as endotracheal intubation require considerable practice to achieve precise performance. A "perfect" performance serves as a baseline for the student to then adapt to a changing environment. Students should practice independently only after being approved by an instructor to do so; moreover, students should practice in pairs, with one observing the other during the attempt. A skill sheet should be used during observation to keep students "honest" during practice.

Airway decision-making

As precision is achieved, begin to change the conditions. Present scenarios where the student has to decide whether to proceed toward an intubation, or whether the airway can be maintained with basic life support and/or alternative airway devices such as a supraglottic or laryngeal mask airway. Over time introduce other options such as surgical cricothyrodotomy into the decision-making process.

Simulation in airway management

There has been a keen interest in the medical community in utilizing high-fidelity simulation technology to help physicians and nurse anesthetists to acquire and retain airway management techniques. Several studies have shown that using realistic, simulated manikins can be a more effective training modality than traditional lecture and practice alone4,5.

Simulation allows the educator to deliver an airway specific to the student's learning needs. A beginner's simulated airway may be very straightforward, while an experienced practitioner may require a highly complicated airway to foster learning. A simulated airway can be replicated numerous times until the student's technique is proficient.

Unlike real patients, a high-fidelity airway simulator can be programmed to reproduce many airway complications that allow the student to practice multiple times under numerous conditions. This is unlike the typical operating room clinical rotation, where patients are sedated, are without secretions, and are positioned in optimal situations.

Depending upon the sophistication of the airway simulator, the educator can eliminate most forms of verbal feedback during a scenario, causing the student to rely solely on their assessment findings to determine which airway management technique to use, and whether the intervention is effective. Physiologic parameters such as pulse rate, respiratory rate, oxygen saturation and exhaled carbon dioxide levels can be provided that help guide the student's decision-making process, without extraneous input from the instructor.

However, there are drawbacks to using airway simulators. They are costly to buy and maintain, and the learning curve to operate them can be steep. Understanding the principles of simulation-based training is critical to its success. Overcoming these challenges can result in a significantly more effective training environment for intubation and other airway management techniques.

Advanced airway management is a complicated, yet precise task that requires a high level of proficiency. Given the low frequency of patient contacts that require intervention, combined with the high costs of complications when procedures fail, it's critical that EMS providers learn good techniques from the start and continue to practice them.


1. Wang HE, et al. Procedural experience with out-of-hospital endotracheal intubation. Critical Care Medicine, 2005; 33(8): 1718–1721.

2. Personal communications regarding the average number of live attempts at intubation in clinical and field phases of paramedic training from June 2013 to June 2014; 17 June 2014.

3. J. Vozenilek, J.A. Cabel, J.J. Flaherty. Evaluation of traditional lecture versus medical simulation training in airway management. Annals Emergency Medicine, 2004; 44(4): S77-S78.

4. Cortegiani A et al. Simulation­based education for cardiopulmonary resuscitation and airway management protocols: a brief report of a systematic review and meta­analysis. Critical Care Medicine, 2014; 18(Suppl 1):P482.

5. Kennedy CC et al. Advanced airway management simulation training in medical education: A systematic review and meta­analysis. Critical Care Medicine, 2014 Jan; 42:169.


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