Airway Management Research Update: Uptight Doctors, Upright Patients

Airway Management Research Update: Uptight Doctors, Upright Patients

By Mike Rubin Apr 18, 2017

The moment one of my paramedic preceptors characterized endotracheal intubation as “a manhood thing,” my self-esteem very much depended on getting the tough tubes. That’s partly why I’m feeling pretty good about myself right now, even though my last intubation was years ago.

If, like me, you’ve been a medic since A came before B and C in the holiest of all algorithms, perhaps I can brighten your day, too, by publicizing a 2015-16 French study involving 371 intubated patients, 75% of whom had Grade 1 laryngeal views (the clearest of four grades).

According to Dr. Calvin Brown III, whose quarterly airway-management updates have become an indispensable part of my continuing education, the first-pass success rate by 290 ICU residents—actual doctors, folks—was only 65%.

Holy Foley, that’s less than two-thirds! Much less than three-quarters! If my stats had been no better than that when I was partnering with Miller and Mac, remediation would have been merciless and swift.

I wish I could stop here and spend the rest of the morning feeling superior to people with six or seven times more medical training than I have, but I really should share the rest of the results with you.

Half of those 371 patients (plus one) were intubated using video laryngoscopy (VL); the rest with direct laryngoscopy (DL). There was hardly a difference in first-pass success. In other words, among “scared intubators,” as Brown calls the participating physicians, VL did not offer an advantage—a finding that would seem to conflict with much of the favorable research on video laryngoscopy presented during prior webinars.

I wouldn’t expect Brown to revel in the awkwardness of youthful doctors as only a medic could; instead, he pretty much discounts the whole study by pointing out:

  • Airways with Grade 1 views are not the easiest to intubate with VL because of the hyper-curved blade’s interference with the tube in the glottic inlet. Experienced VL users know to pull back a bit on the handle.
  • The laryngoscope used for the study, a McGrath MAC, is not, in Brown’s opinion, the best VL model.
  • The Japanese Emergency Airway Network, a registry of 11,000 endotracheal intubations since 2010, shows their first-pass success rate has increased from 68% to 74% as VL has evolved from a virtually unknown airway-management option to the tool of choice in 40% of intubations.

The take-home message? VL still rules over DL, but only if you know what you’re doing.

The second half of Brown’s presentation focused on the positioning of obese patients during laryngoscopy. Let’s start with an important reminder that was implied in the podcast but not stated: You’re going to want to straighten those airway axes by aligning the ears with the sternal notch. For the morbidly obese, that might mean stuffing behind their torsos all the pillows and blankets you can find.

Once the patient is on your stretcher, a study of 231 intubations in two EDs showed an increase in first-pass success from 66% to 86% by also elevating the head from supine to upright (at least 45 degrees).

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If you’re no taller than my wife—5’1” at her most menacing—I know what you’re thinking: How am I going to reach around the top of that cot to insert the laryngoscope?

Worry not, little person. The odds of you passing that tube become measurably more favorable for every five degrees you raise the head. Just bring your tactical step-stool and do your best.

See all of Airway World’s quarterly research updates at

Mike Rubin is a paramedic in Nashville, Tennessee and a member of EMS World’s editorial advisory board. Contact him at

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