25 years later: Airway device evolution since 'Emergency!'
Unlike Johnny and Roy, today's EMS providers have many types of devices to choose from
By Jeff Birrer, EMT-P
Over the past 25 years of EMS, we've seen an amazing proliferation of devices and techniques to control a patient's airway for the purpose of oxygenation, ventilation and protection.
Looking back to one of the first examples of EMS on television, "Emergency!," we watched Johnny and Roy call Rampart to ask permission to insert an Esophageal Obturator Airway, or EOA.
Today, in many parts of the country, we have EMS providers performing advanced levels of airway management, which, not too long ago, were previously only done in the operating room by anesthesiologists.
With the increased complexity of medication-assisted airway management (RSI, RSA), we have need for better rescue devices; unlike Johnny and Roy, today's EMS providers have many types of devices to choose from.
In the hierarchy of airway management, Oral Tracheal Intubation (OTI) is still considered the king by many. But there is a large volume of literature and experience with alternative devices, and we have also added technologies designed to stabilize patients and fend off the need for OTI.
These devices fall into several categories, which have different qualities, both pluses and minuses, and are manufactured by various companies.
The Bag Valve Mask (BVM) with an oral pharyngeal and/or nasal pharyngeal airway is the first line of rescue for failed intubation. Even though this is considered a "basic skill," the ability to BVM patients to maintain or increase oxygenation and ventilation remains difficult for many providers to master and maintain their skills adequately.
The alternatives to OTI mostly fall into extraglottic and supraglottic devices. The extraglottics are those devices that have a smaller distal balloon, which seal the esophagus, and a larger proximal balloon, which seals the posterior or hypopharynx.
Supraglottic devices are those that have a pillow or mask that seals directly around the glottis; these devices are generally referred to as a Laryngeal Mask Airway ( LMA).
Many of the supraglottic and extraglottic devices can be used to facilitate OTI either with the use of a Bougie or endotracheal tube introducer, while others allow direct insertion of an endotracheal tube directly through the device and glottic opening into the trachea.
Both types of these airways provide greater protection form aspiration and maintain a better seal than standard BVM ventilation. Think of these devices as an internal BVM; they move the mask seal from the face to above and below or around the glottis.
Endotracheal tube introducers, also known as Bougies, are the 10 dollar solution to the million dollar problem. They give you the advantage of putting a small stick in a bigger hole as opposed to a well-fitting tube in a similar size tube. With a coude tip, they allow the operator to introduce a tube into a high grade or anterior airway.
In the past 10 years, EMS use of Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure devices (BiPAP) have allowed us to treat COPD and CHF patients that would have previously been intubated without exposing them to the associated complications and risks (ventilator acquired pneumonia, for example) and reduce their overall hospitalization by several days per patient, saving tens of thousands of health care dollars. Not bad for a device that costs about $50 per use.
End Tidal CO2 measuring devices have made it possible to accurately assess our patient's ventilatory and circulatory status continually breath by breath, while pulse oximetry allows us to trend how well we are oxygenating our patients.
With the advent of Video Laryngoscopy (VL), Direct Laryngoscopy (DL) for OTI is becoming a lost but necessary skill. VL is gaining a large foothold in the operating suite and, with the explosion of VL devices and the rapidly falling cost in easy-to-use portable devices, it's likely to become increasingly popular for prehospital OTI in the years to come.
Many of the studies on VL have shown that VL is much easier to learn — six to 10 intubations versus up to 100 for DL to attain proficiency.
These studies also suggest better retention of skills with fewer attempts at OTI. It is worth noting that many of the devices have the ability to record, play back and store evidence of your intubation; many manufacturers are also working on interfaces to attach the video files to major electronic charting platforms.
On the other hand, other manufacturers have been working on improving the laryngoscope itself. An example is Intubrite. The handle is made of lightweight aluminum and powers a combination of white and ultraviolet light in order to brightly illuminate the larynx and spotlight the vocal cords.
The only question EMS providers and agencies need to answer at this point is which devices are best and most effective, looking at efficacy and cost, for their agency.
The best way is to make these decisions is to do research. There are volumes of literature on these devices, and you should look to trial the devices in your system. I would suggest trying more than one of each type or class of device you are considering.