It started as a simple lift assist, helping another crew get an obese CHF patient out of his house and into the rig. Soon, however, it became apparent that the responding crew would need more than just extra muscle to manage the patient.
His level of consciousness was deteriorating, and his oxygen saturation and capnography readings were worsening despite the CPAP the responding crew applied. Before we could muscle him out of his cramped, dark bedroom, he stopped breathing altogether, and the first-in medic looked at me hopefully and asked, “Get the airway for me?”
This is the way most EMS war stories start: “So there we were, with a 460-pound snowman CHFer who needed a tube, with only me and my trusty laryngoscope standing between him and certain death. And that’s when it happened: A deep voice boomed from above, ‘Need any help, son?’ and shaft of white light bathed the patient’s face…”
No, really, that’s the way it happened. I don’t know where the cop came from, but at the moment I was immensely happy to see him and his xenon flashlight. After I handed him a pair of gloves from my thigh pocket, he probably regretted the offer, but together we managed to get the airway secured.
Paramedics have long prided themselves for intubating under conditions that would daunt the most skilled anesthesiologist, but challenging conditions are not an acceptable excuse for failure. What matters are results. This article explores strategies for managing difficult airways in the prehospital environment, focusing on the tools and techniques available to EMS providers.
Airway management is not merely a psychomotor skill to be utilized when the patient can no longer manage their own. Rather, it is a mindset and a constellation of skills, tools and techniques that we employ not only to manage non-patent airways with various adjuncts, but also to preserve patients’ ability to manage their own airways.
The following are strategies we can use to manage difficult airways.
1. It’s not about the tube
There is a reason we call it airway management. The goal is not to employ a specific device, but to ensure adequate oxygenation and ventilation. As long as that goal is achieved, it should not matter whether we use an oropharyngeal airway, a King LTS-D, an endotracheal tube or simply lean over and tap our narcotic overdose patient on the shoulder and remind him, “Hey, buddy, take a breath,” whenever we see the capnograph waveform pause for longer than we deem comfortable.
Airway management is not just one thing; it is a continuum of interventions ranging from simple positioning to surgical cricothyrotomy. Generally we need only progress as far along the continuum as is necessary to achieve adequate oxygenation and ventilation.
In the aforementioned narcotic overdose patient, if we can keep our lethargic, somnolent patient breathing adequately during transport by the simple act of engaging him in conversation, shouldn’t we do that, rather than resort to an invasive airway procedure or risk the effects of narcotic withdrawal by using naloxone?
2. Positioning makes a difference
Supine positioning can result in a marked reduction in functional residual capacity and some decrease in total lung capacity, particularly among the obese,1 and a 25-degree head-up position has been demonstrated to be superior to supine positioning in preoxygenation of obese patients.2 We should weigh the benefits of supine positioning versus the risk of respiratory decompensation and transport our patients in semi-Fowler’s position whenever possible. Positioning is equally important when preparing the patient for insertion of an airway adjunct. While the sniffing position is generally considered optimum for aligning the axes of the airway in direct laryngsocopy, there has been little consensus on what the sniffing position actually is. Many providers simply hyperextend the neck in an attempt to better visualize airway structures; in reality this practice may misalign airway structures and make visualization more difficult. Achieving the sniffing position requires not hyperextension, but flexion of the neck—roughly 35 degrees, with 15 degrees of head extension.3