A recent discussion on advanced airway management drew strong opinions from across the profession. The debate centered on whether endotracheal intubation should remain a core paramedic skill or whether supraglottic airways (SGAs) should serve as the primary tool in most prehospital settings.
Below is a sampling of reader responses.
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ETI: A definitive airway
Many readers argued that intubation remains the definitive airway and should not be replaced.
- “ETI IS the gold standard in airway securement. Supraglottics are handy as backup airways, or a rapid airway to quickly evac a pt out of a dangerous situation. But you will not find a pt in a hospital that needs to be vented with a supraglottic airway.”
- “Because ... supraglotic airways aren’t definitive airways. Longer transports could cause issues. As a backup for an ETI fail, good choice.”
- “Intubation needs to stay. Supraglottic airways should be a backup or if an airway is need for quick evacuation from something. Intubation protects the airway. I also think that hospitals, especially teaching hospitals, should allow medics in the OR to intubate in order to keep up proficiency.”
- “Yes we should. The COPD patient that is in a rural setting an hour from definitive care does not benefit from a supraglottic airway. We should be intubating all cardiac arrests so it becomes muscle memory so you as a provider are confident in taking those difficult airways when needed!”
- “Paramedics should keep ETI. We just have to keep our standards high. IGels, to me are OK for a quick airway short term … we need a definitive airway.”
- “You can’t use a SGA on a burned or reactive airway. Or if they have esophageal varices.”
- “A supraglottic airway is not good enough for a patient that has PEEP settings so high they need the tube clamped.”
Research, proficiency and system design questions
Others did not argue for eliminating ETI outright but questioned whether universal intubation expectations match current call volume and training realities.
- “Supraglottic airways are being pushed as first line tools for medics primarily because a lack of sufficient number of actual cardiac arrests and respiratory failure patients requiring practice of the intubation skill. If you are going to attempt a tube 3 times a year, you simply are never going to be on target. Departments with low utilization are simply surrendering the laryngoscope instead of instituting mandatory monthly practice and purchase of the advanced tools.”
- “Supraglottic airways provide near no airway protection, dislodge easily. Intubation skills have definitely diminished over the last several years. I suggested cadaver labs or OR rotations to sharpen skills. A plastic practice manikin doesn’t help one improve past learning a skill.”
- “Not advocating one way or another — I thought there was some research that showed iGels were non-inferior to an ETT in prehospital setting, similar neurological outcomes, higher first-pass success rate. Has that been debunked?”
- “The issues I see are how much we intubate any more. We need to keep our skills set up because we just don’t push that many tubes anymore. Doing flights, I had quarterly check offs on this skill to keep up the muscle memory.”
Some readers pointed to provider deployment models as a root cause of skill decay.
- “Rethink provider deployment strategies. Low frequency/high risk procedure, but everyone has to be a paramedic and every engine has to be a ‘paramedic’ engine. Too many providers with not enough opportunity to maintain proficiency.”
- “It always should be paramedics intubating or doing XYZ skill. We should be using paramedics for what they are trained to do instead of the 80-90% BLS appropriate calls that we continually send them on. There are far more things that I myself am uncomfortable with on some transfers than I am on advanced airway management on 911 calls.”
- “ETI was the standard before supraglottic airways were useful. I remember the old days of the EGTA and the like. As stated by others the concept that every fire truck has to be ALS just dilutes the pool of proficient providers and leads to these ideas of removing skills because the 8th paramedic to show up on scene haven’t gotten the practice to keep their skills sharp.”
A case for SGAs in some scenarios
A minority of comments clearly favored supraglottic airways in routine practice.
“IGel all day, especially when you need to carry a code, and they normally don’t walk.”
The larger issue
The comments reflect more than a device preference. They highlight ongoing tension around:
- Skill frequency vs. skill importance
- Training access and OR rotations
- Rural transport times
- ALS deployment models
- Maintaining high standards across expanding paramedic ranks
Whether systems prioritize ETI, SGAs or a tiered approach, readers agreed on one point: airway management policy cannot be separated from training expectations and workforce design.
Weigh in: Should paramedics be intubating?
Should paramedics be intubating? Why not just use a supraglottic airway? Where do training and deployment models play an important role in airway decisions? Share your comments.
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