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.
EMS1 readers respond
“I believe we should be intubating every patient that is in need of an advanced airway. I believe supraglottic airways are the quick & easy way. Advanced skills are not being used. What does the ER do when you arrive? They pull out the IGEL and intubate.”
“Intubating has been an automatic skill almost without thinking. Patient stabbed in the neck, unconscious, airway not secure, asked partner for an 8.0, put laryngoscope in, no room for an 8.0, neck swelling, got a 6.0, went in, by the time we arrived at ER the neck looked like a small watermelon. A bona fide save. This same type of story repeats itself all over the country. You cannot get good airways with any other object.”
“Endotracheal intubation is a highly technical skill, that can be taught and learned by appropriate professionals. Although retired now, I still feel confident in my skills. We had monthly code blue drills on the fire dept. I worked for, and I was an ACLS instructor, who most often taught/tested the airway station. In that position, and in actual practice, I observed doctors and paramedics who should not attempt ETI. I also saw physicians who knew their skills in ETI were not what the patient needed, and these doctors referred that task to others more skilled in ETI. That was a good lesson: who is the best at this skill, are they present/available, is there adjunct equipment available in case ETI skilled personnel are not immediately available? ETI remains the gold standard for the most secured airway. The supraglottic airways were developed to be used in the acute surgical setting, where qualified, skilled, experienced staff is present and the security of that airway is not as challenged, as those in-field cases are. The SGA has a place in EMS, but that place is most often second in line to the ET tube system. During my service as an RN, CEN, REMT-P, I was employed both on the fire department as well as the local medical center, as a house supervisor. As an RN, I was trained to intubate but by state law was not allowed to do so. In working as the house supervisor, my employer allowed me to perform intubation since I was still a working, licensed paramedic. There were many times when a code was called, and I would be able to intubate, start an IV and begin the 1st course of ACLS, before the house physician arrived. Very efficient and effective emergency care. I personally never failed to place an ET tube when the situation warranted it, with my youngest patient being 4 months and the oldest being in her 9’s. There are only 2 ways to perform ETI, those being the right way and the wrong way. Very similar to those who are not the best at placing IVs ... use your best personnel to do the most technical work, that they are qualified to do. This is providing the best patient care.”
“Paramedics absolutely should be intubating, the iGel is a good tool for clean airways in short-duration scenarios, not a long-term definitive airway. There is literally no scenario in which a iGel is preferable over the long-term to an endotracheal tube.”
“As technology evolves like prior to video scope it was a skill that you developed with practice. It cost time on scene, then video scopes come along and 90% 1st time pass. It will only improve with technology. Get the superior airway control it. Yes, no question paramedics should tube them!”
“I totally agree we should keep intubation in the scope of practice for paramedics. Having said that, who can intubate in a system is of grand debate. There is a mismatch of demand for ALS skills; a ton of patients need 12 leads, not many need intubation. I would advocate for a select cadre of ground, critical care-level paramedics to be intubation-capable within a 911 system; the other paramedics would use SGAs and call for backup if a patient might need intubation. Similar to the Australian model of EMS- not every paramedic needs to be capable of intubating.”
“Yes. Paramedics shouldbe and not lose the skill we have learned. Supraglottic is good as back up, but not a first-in-line go-to! A lot of educators have gotten comfortable teaching to use the back ups and not push for the learned skilled to intubated correctly.”
“In my humble opinion, paramedics should be intubating ... with video laryngoscopes ... every time. Studies suggest video laryngoscopy improves ‘first pass’ success. Video laryngoscopy is the standard for ED physicians and flight medics. Video laryngoscopy should be the airway standard for ground medics, as well. I think traditional laryngoscopes should remain on the ambulance as a back up in case of equipment failure, but the video laryngoscope should always be the primary intubation tool.”
“Paramedics are responsible for maintaining their skills. If you can’t get your e-t tube in first, then use your backup plan. Think about your patient and do the best for them. The endotracheal intubation has worked well for me over all my years in EMS and I will continue this skill and not sell out to easy or fast insertion of a lesser airway.”
“As an operating room RN & paramedic, I have always been taught the definitive protective airway is an endotracheal tube. It’s necessary for ventilator use, as an LMA doesn’t allow for higher pressures. Also, the LNA seal may not be good enough to protect for aspiration if the patient vomits. We’re all ACLS certified, many, like myself, are also PALS & ATLS certified. We keep an intubation head & equipment (with Mac & Miller blades), ET tubes, & LMAs. As a training officer & AHA instructor, I always encourage frequent practice to stay current with techniques. I’m lucky to have anesthesia docs who are willing to let me intubate our surgical patients (as student medics do in their OR rotations). Practice, practice, practice. Thankfully, in Ithaca, NY, our ambulances are always staffed by 2 medics, with IFD rescue trucks as support. Our supervisor SUVs are staffed by one medic, but again, they respond in addition to regular crews as needed, as well as meeting up with outlying/rural FD crews who may not always have ALS crews available. 2-person crews are optional for great patient care!! If more staff needs to be hired for safety, then so be it!”
“With the bougie and video laryngoscopy, there should be no reason for low success rates with intubations on first attempts. It’s not about ego and trying to prove the skills, it’s about getting the job done now. Paramedics should intubate as soon as feasible after achieving ROSC, especially when you have a longer transport time, or when airway cannot be controlled. Most of the time, the docs do it as soon as you get into the ER doors.”
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