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The Ambulance Driver's Perspective
by Kelly Grayson

Advanced airway tips for the BLS provider

No matter who is holding the laryngoscope, airway management is a team sport

By Kelly Grayson

 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.

About the author

Kelly Grayson, NREMT-P, CCEMT-P, is a critical care paramedic in Louisiana. He has spent the past 18 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a former president of the Louisiana EMS Instructor Society and board member of the LA Association of Nationally Registered EMTs.

He is a frequent EMS conference speaker and contributor to various EMS training texts, and is the author of the popular blog A Day In the Life of an Ambulance Driver. The paperback version of Kelly's book is available at booksellers nationwide. You can follow him on Twitter (@AmboDriver) or Facebook (, or email him at

The comments below are member-generated and do not necessarily reflect the opinions of or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
Melissa Mason Mosner Melissa Mason Mosner Thursday, October 02, 2014 7:43:38 AM Helpful and clearly described.
Jeff Birrer Jeff Birrer Thursday, October 02, 2014 9:25:40 AM A skilled operator should pick the blade based on assessment not preference also positioning ( Tregus level with stern all notch face parallel to the ceiling) along with the things described in the article along with a BOUGIE
Daniel Gerard Daniel Gerard Friday, October 03, 2014 9:37:55 AM BURP AND cricoid pressure are the absolute worst techniques for improving laryngeal view. Bimanual manipulation/laryngoscopy is the correct technique, far superior to BURP and cricoid pressure.
Ray Noll Ray Noll Friday, October 03, 2014 11:49:45 AM How did I know that DG would be on this site too.
Matt Myers Matt Myers Friday, October 03, 2014 3:28:46 PM I personally have gotten much better views using BURP. I believe in it and try to use it if I'm having difficulty visualizing. It can make a grade 4 a grade 1 very easily.
Kelly Grayson Kelly Grayson Saturday, October 04, 2014 12:01:06 PM Dan: 1. There's a big difference between cricoid pressure and BURP, and I say so in the article. 2. Coaching a BLS partner through BURP is not so different a technique from bimanual manipulation. The only difference is, the laryngoscopist provides the pressure first, and then asks an assistant to take over. 3. "Absolute worst techniques" is pretty strong language, and quite frankly, Dan Gerard opinion masquerading as fact. Is it less effective than bimanual manipulation, at least according to Levitan? Quite possibly. "Absolute worst techniques?" Not hardly, and certainly better than nothing at all.
Daniel Gerard Daniel Gerard Saturday, October 04, 2014 12:49:41 PM Kelly Grayson It doesn't make a difference whether you are talking BURP or cricoid pressure. They are both poor tools. In order to improve quality of care here we need to base our actions on data (numbers) and science (scientific observation to support the efficacy and efficiency of what we propose that is submitted for peer -review)... Teaching and using bimanual manipulation, I have seen improvement in intubation success rates from 57% first pass success to 100% in one moderate EMS system, and from 78% to 94% success rate first pass in a large urban EMS system. Bimanual manipulation/laryngoscopy is the correct technique. BURP and cricoid pressure increase difficulty and mortality. First time pass rate is the KEY to survival in performing intubation and maintaining an airway ("The importance of first pass success when performing orotracheal intubation in the emergency department. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. Acad Emerg Med. 2013 Jan;20(1):71-8. AND Emergency Tracheal Intubation: Complications Associated with Repeat Laryngoscopy Mort TC. Anesth Analg 2004; 99:607–13) Use of Bimanual manipulation is supported by science and the literature.,,,, If there is science or data to support the continued use of cricoid pressure or BURP technique, I would suggest that this evidence be put forward, let us see the clinically relevant data/scientifically peer-reviewed article that supports BURP. Other wise advocating the continued use of BURP/cricoid pressure may increase mortality and morbidity in a fragile and vulnerable population. Airway is a lethal skill. I am talking about your personal skill as a provider Kelly. Because you have had success with it, I applaud you. If you have clinically valid data from a significant number of patients to support the accuracy of your support of BURP over anything else, and not just a casual relationship that may be influenced by the provider who is performing the skill, you would be obliged to put forth that data in some type of article for clinical scrutiny in order to benefit the profession. This isn't to knock your proficiency as a provider of advanced life support Kelly. If you have had success, you may be the exception and not the rule. If you teach the skill a particular way or perform it it differently than other providers, than maybe that is the key to success. In that case, replication of your technique, in a clinical education environment and again for patients in order to achieve results may be what is called for here.

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