10 Steps for Smarter Intubation

Endotracheal intubation is a fundamental skill performed by paramedics. While it’s 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. The following explains the unique challenges paramedics face while performing intubation, the problems found in studies of paramedic intubation, and 10 steps to improve intubation performance.

Paramedic 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 are 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 Paramedic 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.^3,4,5

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 in a year 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.

Smarter Intubation

If intubation continues to be performed by paramedics, a smarter approach must be taken. Professional associations must advocate for more live clinical experience during school. EMS systems must monitor intubation performance and ensure each paramedic’s proficiency. Equipment must be available to help intubation and monitor tube placement after. Individual paramedics must recognize when intubation is appropriate, when it is not and when to stop an intubation attempt.

ETI should be considered one option for airway management that may not be best for some patients. For cardiac arrest, chest compressions and defibrillation should never be compromised to place any airway device. For patients with a pulse, other airway management options and transport time must be considered to determine if intubation should be done in the field.

Once the decision to proceed with intubation is made, steps should be taken to maximize the chance of first-pass success. The following steps provide a methodical approach to manage the airway of any intubation candidate. It emphasizes preparation, use of techniques that help intubation and when to use a supraglottic airway device instead. The problems that intubation is intended to help should never be made worse during the procedure. Remember, no intubation is always better than bad intubation, even if an ET tube is eventually placed.

1. Practice

Professional athletes would never swing a baseball bat or golf club in a game or tournament without taking practice swings first. Paramedics are called upon to perform complex skills in adverse conditions—skills they may only practice a few times each year. This is why paramedics must practice airway management as often as possible before the next call.

Intubation involves much more than passing an ET tube through vocal cords. Packages must be opened, equipment must be prepared, fine motor control is needed and critical thinking is required at each step. Repeatedly practicing each step will make them easier to complete during an emergency. Go through an entire airway management scenario, including intubation failure, with a mannequin at the beginning of each shift.

2. Determine if intubation is indicated

The use of basic adjuncts to manage a patient’s airway or placing a supraglottic device may be better than an ET tube for some patients. Some excellent EMS systems have high cardiac arrest resuscitation rates with supraglottic airway devices. Before intubating a patient in cardiac arrest, ask if it is possible to do so without interrupting chest compressions. For patients with a pulse, ask if adequate ventilation and airway protection can be achieved with a less invasive method until you get to the hospital. A successfully managed airway does not have to be intubated.

3. Prepare the patient

Since paramedics only intubate in emergencies, there is often a sense of urgency and need to rush through the procedure. Lack of preparation often leads to failure. Basic steps taken with each patient before the intubation attempt will increase the chance of first-pass success.

Start with the basic airway adjuncts. Insert a nasal airway and oral airway if the patient will tolerate it. Preoxygenate the patient before an intubation attempt to increase their reserve capacity, but never hyperventilate a patient to do this. Hyperventilation is harmful for a number of reasons.

Suction every patient’s mouth with a rigid suction catheter. It will much be easier to visualize the airway landmarks if secretions are suctioned before the laryngoscope is introduced. This can be done during chest compressions, between ventilation with the BVM or with an oxygen mask in place.

To align the airway landmarks for better visualization, position the patient’s head so the ears are level with their sternum. This is best done by placing blankets, towels or pillows under their head and shoulders.

4. Prepare your equipment

Assemble all of your equipment, including backup devices, before attempting intubation. Start by attaching the capnography circuit to the BVM. Assemble the ET tube with a stylette and syringe and check the light source on the laryngoscope. Have the bougie and supraglottic device out as well. All equipment that might be needed should be within reach and not have to be located in a bag after the attempt begins.

5. Advance the laryngoscope blade

With the patient’s head in position, their mouth suctioned and your equipment ready, introduce the laryngoscope blade. Imagine asking the patient to open their mouth wide. Advance the blade down the tongue and identify the epiglottis.

If using a curved blade, insert the tip into the vallecula, which is just above the epiglottis. With a straight blade, advance the tip just past the epiglottis. Gently lift the blade forward and aim for the patient’s left foot.

For novice intubators, there’s a tendency to panic if the vocal cords are not immediately visualized after the laryngoscope is introduced. Identifying the epiglottis first and recognizing other airway landmarks will prevent this. Think of it as a “You Are Here” mark on a map and the trachea is above and behind it. If the trachea can not be visualized after it is moved, proceed with the following steps.

6. BURP

Applying Backward, Upward, Rightward Pressure to the lower third of the thyroid cartilage may help bring the airway landmarks into view. While your left hand holds the laryngoscope, place the middle finger of your right hand just below the thyroid cartilage. Gently pull it toward the patient’s right ear.

Do not lose sight of the landmarks once they are found. Either have an assistant hold them in that position, or gently let go of the cartilage with your right hand while you manipulate the laryngoscope to keep them in view. Your right hand is now free to pass the tube.

The BURP maneuver is different from cricoid pressure. Pressing the cricoid cartilage downward is believed to close off the esophagus and help prevent aspiration. Its effectiveness has been questioned and it can impair the view of upper airway structures during intubation. Pressure is applied to the thyroid cartilage during the BURP maneuver, and is designed only to assist in viewing airway landmarks. If cricoid pressure is applied during ventilation with a BVM and landmark visualization is limited during intubation, consider releasing it and try the BURP maneuver.¹⁰

7. Bougie

If you have sight of the epiglottis but a limited view of other airway landmarks, consider the bougie next. Also known as a flex-guide ET tube introducer, this is a curved tip stylette which is easier to place than a larger diameter ET tube. Place the upward tip behind the epiglottis and advance it.

When placed in the trachea, vibrations are usually felt as the tip passes against the tracheal rings. Resistance should also be met after it is advanced approximately 20 cm when the trachea narrows. This is marked with a black line. Slide the ET tube over the bougie, and rotate the tube if resistance is met. Assume the bougie is in the esophagus if no resistance is felt.

8. Abandon the attempt and reassess

An intubation attempt should be stopped if:

• Compressions must be interrupted on a patient in cardiac arrest
• A patient with a pulse desaturates or becomes bradycardic
• Airway landmarks are not located after the previous steps.

Resume basic airway management and assess why the attempt was unsuccessful. Then think about what would be different with a second intubation attempt. Success is unlikely if the same paramedic uses the same laryngoscope blade under the same conditions as the first attempt. At this point the smartest step is usually to place a supraglottic device.

9.  Confirm placement

During episodes of “COPS,” viewers frequently see people get arrested after breaking the law. Although millions of viewers watch a suspect break the law, a narrator reminds viewers all suspects are innocent until proven guilty in a court of law. The same concept applies to confirming placement of an airway device. Even if the tube was visualized passing the landmarks, it must be proven by the following methods.⁹

The most reliable method to confirm tube placement is waveform capnography. Each breath produces a waveform and a numeric value of the amount of carbon dioxide exhaled with each breath (called end-tidal CO₂, or ETCO₂). Continuous monitoring provides immediate feedback if the device becomes misplaced. A normal ETCO₂ level is 35-45 mmHG. Expect it to be lower in patients in shock or cardiac arrest and higher in patients with respiratory failure. Having the circuit attached to the BVM prior to intubation will provide a baseline for what the post-intubation ETCO₂ level should be.

Listen to the patient’s epigastrium with a stethoscope and look at the monitor during the first ventilation through the tube. A waveform should appear on the monitor and only faint sounds should be heard over the epigastrium. Gurgling sounds with a very small or absent waveform indicate the tube is misplaced. Remove it before another ventilation is delivered and resume basic management.

Listen to both sides of the patient’s chest next. Breath sounds should be equal on both sides. Breath sounds on the right side but not the left indicate the tube is too deep. Pull it back slowly until breath sounds are equal.

10. Secure the tube

Once tube placement is confirmed it must be secured with a commercial device or tape. Never rush this step and pay close attention to details. If vomit or blood are near the patient’s mouth, wipe it off before the tube is secured. A cervical collar can help keep the tube in place by limiting head movement during patient movement.

Like many things in EMS, the choice of device is less important than how it’s used. While securing the tube, imagine a worst-case scenario. Would it still be in place if the patient was accidentally dropped down stairs?

It is also important to be prepared if the tube becomes displaced. An assembled BVM should stay with any intubated patient.

A Note on Ventilation

Another problem associated with intubation is hyperventilation after the tube is placed. This causes a decrease in cardiac output and cerebral perfusion. Mechanical ventilation is complicated and beyond the scope of this article, but as a rule the ventilation rate and tidal volume should be titrated to maintain an ETCO₂ reading of 35-45 mmHg and pulse-ox reading above 95%.

Airway Trick: The MAD Bougie

EMS people are known for their MacGyver-like ability to improvise. A mucosal atomizer device (used for intranasal medication delivery) can be attached to the bougie so that it serves the same function as a traditional stylette (see Figure 1). Here’s how it works:

1. Remove the plastic center piece of the MAD and slide the soft cone onto the distal end of the bougie (Figure 2).  

2. Slide the ET tube onto the bougie. Position the cuff half way between the bougie’s 20 cm line and the curved tip. Use the cone of the MAD to hold it in place (Figure 3).

3. Hold the ET tube between the bougie’s 20 cm line and the cuff with your right hand during the intubation attempt. Grasping the larger diameter ET tube makes it easier to direct the smaller-diameter tip of the bougie into the trachea. Advance the bougie until resistance is felt or you visualize the cuff passing the landmarks. (Figure 4).

4.  Slide the ET tube forward and remove the bougie. Position the tube 20 cm at the patient’s lips. Inflate the cuff and confirm placement (Figure 5).

For more about the bougie and mucosal atomizer devices, see Bougie It! and Intranasal Drug Administration.

Conclusion

Placement of an ET tube can provide life saving ventilation and airway protection, or cause debilitating brain damage. The outcome depends on frequent practice, choosing the right patients to intubate, recognizing complications and using a different method if any arise. First, do no harm.

References

1. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Annals of Emergency Medicine, 2001; 37: 32–37.
2. Davis DP, Hwang JQ, Dunford JV. Rate of decline in oxygen saturation at various pulse oximetry values with prehospital rapid sequence intubation. Prehospital Emergency Care, 2008; 12(1): 46–51.
3. Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy DM. Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Annals of Emergency Medicine, 2004; 44(5): 439–50.
4. Stiell IG, Nesbitt LP, Pickett W, et al. The OPALS major trauma study: the impact of advanced life support on survival and morbidity. Canadian Medical Association Journal, 2008; 178(9): 1141–52.
5. Davis DP, Hoyt DB, Ochs M, Fortlage D, Holbrook T, Marshall LK, Rosen P. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. Journal of Trauma, 2003; 54(3): 444–53.
6. Wang HE, Simeone SJ, Weaver MD, Callaway CW. Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation. Annals of Emergency Medicine, 2009; 54(5): 645–52.
7. Wang HE, Seitz SR, Hostler D, Yealy DM. Defining the learning curve for paramedic student endotracheal intubation. Prehospital Emergency Care, 2005; 9(2): 156–62.
8. Johnston BD, Seitz SR, Wang HE. Limited opportunities for paramedic student endotracheal intubation training in the operating room. Academic Emergency Medicine, 2006; 13: 1051–1055.
9. Wang HE, Kupas DF, Hostler D, Cooney R, Yealy DM, Lave JR. Procedural experience with out-of-hospital endotracheal intubation. Critical Care Medicine, 2005; 33(8): 1718–1721.
10. Levitan RM. The Airway Cam Guide to Intubation and Practical Emergency Airway Management. Wayne, PA: Airway Cam Technologies Inc, 2003.

Robert J. Sullivan BA, NREMT-P, works as a paramedic with New Castle County (DE) EMS and teaches with the paramedic program at Delaware Technical and Community College. Contact him at rsullivan@nccde.org.