10 Steps for Smarter Intubation

by Robert J. Sullivan, BA, NREMT-P
Created: September 1, 2012

When to intubate, how to do it quickly and when to do something else

Step 1: Frequent practice of all steps in a controlled setting increases the likelihood of success in the field.
Step 1: Frequent practice of all steps in a controlled setting increases the likelihood of success in the field.
Step 1: Frequent practice of all steps in a controlled setting increases the likelihood of success in the field.
Step 1: Frequent practice of all steps in a controlled setting increases the likelihood of success in the field.
Step 2: Intubation is not the best option for all patients. Primary use of another device is sometimes better.
Step 2: Intubation is not the best option for all patients. Primary use of another device is sometimes better.
Step 3: Elevating the patient’s head will align the airway landmarks for better visualization. Try to make the patient’s ears level with the sternum, but never interrupt chest compressions to do...
Step 3: Elevating the patient’s head will align the airway landmarks for better visualization. Try to make the patient’s ears level with the sternum, but never interrupt chest compressions to do this.
Step 3: Elevating the patient’s head will align the airway landmarks for better visualization. Try to make the patient’s ears level with the sternum, but never interrupt chest compressions to do...
Step 3: Elevating the patient’s head will align the airway landmarks for better visualization. Try to make the patient’s ears level with the sternum, but never interrupt chest compressions to do this.
Step 4: Have all equipment within reach before attempting intubation.
Step 4: Have all equipment within reach before attempting intubation.
Step 5: Advance the laryngoscope blade and identify the epiglottis. Do not interrupt chest compressions during a cardiac arrest.
Step 5: Advance the laryngoscope blade and identify the epiglottis. Do not interrupt chest compressions during a cardiac arrest.
Step 6: Applying gentle backward, upward, rightward pressure (BURP) to the lower third of the thyroid cartilage will help bring the airway landmarks into view.
Step 6: Applying gentle backward, upward, rightward pressure (BURP) to the lower third of the thyroid cartilage will help bring the airway landmarks into view.
Step 7: With a limited view of the upper airway anatomy, introduce the bougie into the trachea. Once in place, slide the ET tube over it.
Step 7: With a limited view of the upper airway anatomy, introduce the bougie into the trachea. Once in place, slide the ET tube over it.
Step 7: With a limited view of the upper airway anatomy, introduce the bougie into the trachea. Once in place, slide the ET tube over it.
Step 7: With a limited view of the upper airway anatomy, introduce the bougie into the trachea. Once in place, slide the ET tube over it.
Step 7: With a limited view of the upper airway anatomy, introduce the bougie into the trachea. Once in place, slide the ET tube over it.
Step 7: With a limited view of the upper airway anatomy, introduce the bougie into the trachea. Once in place, slide the ET tube over it.
Step 8: Abandon the intubation attempt if not successful. Resume basic airway management and assess why the attempt was unsuccessful. Consider placing an alternative device at this point.
Step 8: Abandon the intubation attempt if not successful. Resume basic airway management and assess why the attempt was unsuccessful. Consider placing an alternative device at this point.
Step 9: During the first breath delivered through the ET tube, listen to the epigastrum and look for the capnography waveform on the monitor.
Step 9: During the first breath delivered through the ET tube, listen to the epigastrum and look for the capnography waveform on the monitor.
Step 10: Secure the tube with a method that will keep the patient’s airway protected in the event of a worst-case scenario.
Step 10: Secure the tube with a method that will keep the patient’s airway protected in the event of a worst-case scenario.
Photo by Crystal DiMauro, AS, NREMT-P

Figure 1
Figure 1
Photo by Crystal DiMauro, AS, NREMT-P

Figure 2
Figure 2
Photo by Crystal DiMauro, AS, NREMT-P

Figure 3
Figure 3
Photo by Crystal DiMauro, AS, NREMT-P

Figure 4
Figure 4
Photo by Crystal DiMauro, AS, NREMT-P

Figure 5
Figure 5

While endotracheal intubation is considered the most definitive tool for airway management, complications are often documented with it. And with other airway devices available, some experts question whether paramedics should even continue to intubate. This article explains the challenges paramedics face while performing intubation, problems found in studies of paramedic intubation and 10 steps to improve intubation performance.

Intubation Challenges

The goal of endotracheal intubation (ETI) is to place a tube in the patient’s trachea that provides an unobstructed pathway for ventilation. While ventilation and airway protection are life-saving, achieving this through ETI comes with a number of risks and challenges. It can be difficult in some patients to locate the correct landmarks and place the tube in the trachea. If the tube is mistakenly placed in the esophagus and the error is not recognized, serious brain damage or death is likely.

Only the sickest and most injured patients should be intubated by paramedics. These patients often have anatomy that makes finding the airway landmarks difficult, have blood or secretions in their airway, or are combative from a head injury. Paramedics also must intubate in uncontrolled environments, such as a small bathroom or dark roadway. Not only are these patients the most difficult to intubate, but it’s attempted under some of the worst conditions.

Problems With Intubation

While it’s intuitive that early intubation of patients with a compromised airway would be helpful, this has not been demonstrated in literature. Studies have found unacceptably high rates of unrecognized tube misplacement, as high as 14% in one system.¹ Periods of hypoxia were noted during prolonged intubation attempts in head-injured patients,² and head-injured patients intubated in the field did worse than similar patients who were not.^3–5

After the importance of continuous chest compressions was published in the American Heart Association’s 2005 guideline revision, a study showed chest compressions were often interrupted for several minutes during intubation.⁶ The procedure harmed several patients in these studies, and it did not help patients in cardiac arrest if compressions were stopped.

Education and Experience

Questions have been raised about initial airway education for paramedic students. More live clinical experience is associated with higher success rates,⁷ but paramedic students get much less operating room clinical intubation time than other students. Reasons for this include alternate airway devices being used in the OR, competition with students from other disciplines and physicians’ fear of litigation.⁸ While the National Standard Paramedic Curriculum recommends paramedic students perform five intubations, it is recommended ED residents perform 35, anesthesia residents perform 20–57, and nurse anesthetists perform 200 during training.⁷

Because the procedure is seldom encountered in many EMS systems, skill maintenance is a concern. Over one year in Pennsylvania, 67% of paramedics performed two or fewer intubations and 39% performed none.⁹ With less initial airway training, intubating in uncontrolled situations and few opportunities to practice, it is not surprising so many problems have been documented.

ETI Alternatives

Other airway devices are now available that can be placed in less time than an ET tube, require less skill to use and carry little risk of misplacement. Instead of a tube in the trachea, these devices isolate the trachea and ventilate through a port above the glottic opening. Known as supraglottic airway devices, they include the Combitube, laryngeal mask airway, SALT and King Airway. One drawback to the supraglottic devices is they may provide less protection from aspiration than an ET tube. Another is they will not ventilate effectively if the upper airway is obstructed. In cases of airway burns, anaphylaxis or severe neck trauma, only a tracheal tube can prevent an airway obstruction from edema. Since these situations are extremely rare, some experts believe supraglottic devices should replace the ET tube for EMS.

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