Latest Research Brings Good News in Prehospital Airway Management

Latest Research Brings Good News in Prehospital Airway Management

By Mike Rubin Apr 03, 2018

If your first paramedic card was issued in a year beginning with 1, you probably self-identify as an airway expert. The best pre-Y2K medic programs insisted students intubate early, often, and from almost any angle relative to wrecked autos and barricaded bathrooms. That began to change in the 2000s, when limited opportunities for hospital-based practice, coupled with doubts about the reliability of prehospital endotracheal intubation (ETI), relegated laryngoscopes to a backup role in the field.

According to Airway World’s latest review of prehospital research, though, paramedics are, indeed, adept at securing airways. New-millennium emphasis on BVM ventilation over ETI may have been premature.

Aggressive Management of Difficult Airways

Calvin Brown III, MD, of Boston’s Brigham and Women’s Hospital, who leads Airway World’s quarterly webinars, began 2018’s March update with a study of rapid-sequence intubation (RSI) by Australian flight medics. Keep in mind that these folks, who complete three years of college-level study plus one year of field work, are at the upper boundary, academically, of anyone in the world called a paramedic.

Of their 795 attempts at RSI over six years, 99% were successful (90% on the first pass). Only 5% of their patients suffered procedure-related hypotension, and 1% became hypoxic. No cricothyrotomies were needed. The headline—that experienced flight medics perform RSI safely and reliably—supports drug-facilitated ETI by highly trained prehospital personnel.

But what about cricothyrotomies? Since none were needed during the study’s six years, should paramedics even be taught that technique? Perhaps, according to a retrospective Tennessee study. 

Of 22,000 patients transported by Vanderbilt LifeFlight over nine years, only 13 needed surgical airways—fewer than two per year at this busy critical-care agency with more than 80 employees. You’d have to be a pretty lucky (or unlucky) paramedic to get more than one cricothyrotomy a decade.

Consider, though, that every one of those 13 crics was successful. That means patients whose lives depended on sure-handed surgery prehospitally got exactly what they needed from trained, if relatively inexperienced, caregivers. Does that mean a basic street medic like me could safely slice through a real cricothyroid membrane after practicing only on polypropylene torsos? According to Brown, “The technique isn’t as tough as the decision; you can do it when you need to.”

Pediatric Intubation Proficiency

Another high-pucker-factor procedure for many paramedics is pediatric intubation. I think you’ll be as pleased as I was to learn getting lots of practice on people of any age is the best way to excel with peds.

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According to Prehospital Emergency Care, my go-to source for EMS-related research, a retrospective study involving 86,000 patients showed that clinicians who treated mostly adults were significantly better at pediatric airway management than those who worked primarily on kids. That the adult specialists had four times as much ETI experience as the pediatric experts was presumed to be a contributing factor. The take-home message: Pediatric intubation is less peculiar than we think.

Bag or Tube?

Advanced airway management by EMS took a big hit about 15 years ago when poor outcomes were linked to time-consuming prehospital tube placement. Many EMS systems discouraged ETI in favor of BVMs with or without supraglottic airways en route. However, a 2015–17 JAMA study found that regurgitation was twice as likely after BVM ventilation alone. This isn’t surprising to anyone who’s bagged a patient in the field; like ETI, it takes practice.

The JAMA data also showed ROSC was more frequent in intubated patients, but survival and neurological outcomes were pretty much equal. Clearly more research is needed.

Nothing against pit crews, Combitubes, mechanical CPR, or C-A-B, but if you’re an old medic like me, you remember when a “good call” included a successful intubation. Postpone retirement another few years and you may see a change back to A-B-C.

See all of Airway World’s quarterly updates at

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

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