Advanced airway tips for the BLS provider

 There is no "I" in intubation.

Whoa, wait a minute. I guess there is an "I" in intubation.  What I should have said was, "There is no "I" in airway," because…

… well, darn it, looks like that one won't work either.

While I may not be coining my own Lombardi-esque EMS catchphrase any time soon, the fact remains that, no matter who is holding the laryngoscope, airway management is a team sport. Doesn't matter if the medic wields his 'scope with all the panache of an airway samurai, a skilled set of hands to assist in the procedure often spells the difference between success and failure.

I was reminded of that fact last week during a particularly difficult intubation. The patient had a short, bull neck, big, floppy tongue, and a jaw so difficult to displace that there was precious little room to see, much less advance an endotracheal tube.

The other medic was running the medications and monitor, and both our EMT partners were brand new, having never even witnessed a resuscitation, much less participated in one. Add to that the fact that the attempt was done while CPR compressions were ongoing, and it only added to the degree of difficulty.

After ripping the distal cuff on a Combitube on the patient's teeth as we advanced it, I made a second attempt at intubation while my partner sprinted to the rig to fetch our spare Combitube. I got it done, but not without a lot of impromptu coaching of our EMT partners in how to assist me with the procedure.

To that end, I'd like to share some advanced airway tips aimed at you, the BLS provider:

• Equipment Setup. Find out what size and shape laryngoscope blade your partner prefers, and set the scope up with that blade. While you're at it, have immediately available the same size blade in a different shape; if your partner likes a MacIntosh #3, set up the scope that way, but keep the Miller #3 handy, just in case.

Most adult males can take an 8.0 endotracheal tube, and most females can take at least a 7.0. For that reason, most providers use a 7.5 tube as their first choice. Set it up with a syringe attached to the inflation port, and make sure the stylet does not extend past the end of the tube. Keep a spare tube readily available. As the saying goes, "Two is one, and one is none."

• BURP Technique. If you've assisted with an intubation before, you may have been asked to provide cricoid pressure, or as some medics refer to it, a Sellick's Maneuver. Usually they ask for this so that they can better visualize the vocal cords, but there's a better way to do it: the BURP Technique. Instead of pressing on the cricoid cartilage, move an inch or so higher to the thyroid cartilage (Adam's Apple) itself.

Backwards, Upwards, Rightward Pressure on the thyroid cartilage will facilitate a better view for the partner performing laryngoscopy. If you're facing the patient, press his larynx back toward the spine, up toward the top of the head, and angled slightly toward the patient's right ear. Your partner can coach you through exactly how much pressure you need to apply.

Often, while you're doing this, you can actually feel the tip of the endotracheal tube pass through the vocal cords.

• Lip Retraction. Sometimes, passing a tube in the tight confines of a patient's mouth can be rather difficult. When space is at a premium, try inserting your finger into the right corner of the patient's mouth like a fish hook, and pull it gently to the right. This substantially increases the room the medic has to pass the tube, as well as visualize the airway structures.
• Confirmation of tube placement.  If you use it, have the capnograph line ready to attach to the endotracheal tube and the monitor. Chances are, your medic partner is already at the patient's head managing the airway, so you may be asked to auscultate the belly and chest to confirm tube placement. It's important that you know what sounds you should or should not hear.

While it's desirable that you hear nothing when you auscultate the epigastrum while your partner ventilates, often you will hear some sound even when the tube is correctly placed. That's because sound will often resonate through the large airways and the diaphragm, and you'll be able to pick it up even when you listen to the belly. This is especially true in children and very thin people.

So, what you actually want to hear is absence of gurgling, not absence of sounds. If what you hear resembles lung sounds, tell your partner, and check to see if there are CO2 readings on the cardiac monitor.

Listen to the epigastrum first, because your partner will want to know if they tubed the goose on the first squeeze of the bag, not the fifth or sixth. If you hear no gurgling there, listen to lung sounds over the lower left lung, then the right, and work your way up to the apexes. Sounds should be equal on both sides.

• Securing the tube. Do you know how to apply the mechanical tube restraint your agency uses? This is part of the choreography you and your partner need to work out before the call, not during.

Try and practice these advanced airway tips, and your assistance just might mean the difference between a successful intubation and a failed one.