How to improve intubation success

With endotracheal intubation, many paramedics lack good training from experts based on sound fundamentals, and are left to their own devices

I'm going to share a few reasons why I think some paramedics have trouble performing endotrachael intubation.

I've concluded we really don't want them to be very good at it. We don't give them good training from experts based on sound fundamentals. We leave them to their own devices and then complain about the results.

It would be easy to fix. We just need to improve airway instruction and use better equipment following industry-specific best practice algorithms.

We need more clinical training from better airway instructors, like members of the anesthesia community. These are the leading airway experts, yet we have precious little exposure to them. A good CRNA or anesthesiologist could take the average paramedic with a decent understanding of human anatomy from student to airway master in a few short weeks. I say weeks, not days.

Recent learning experiences came after considerable personal protest. Two pediatric anesthesiologists, Dr. Peter Szmuk and Dr. Patrick Olomu, wanted to try my new pediatric video-laryngoscope, but they insisted I come down to Children's Medical Center Dallas for a whole week. They said there was really no way for them, or me, to really learn much about the device in only a day or two. It turned out they were right.

I reluctantly agreed, and in one week did maybe 45-50 pediatric cases with them. We used the device on many different ages and grade airways. They even did a few nasal forcep-guided video intubations. By the end of the week I had gained a new confidence with pediatric airways and video-laryngoscopy.

I wish every paramedic could spend just two weeks in a busy O.R. with a great teaching anesthesiologist. If you can, hook up with the pediatric folks. Maybe it's because they deal with kids all day, but they tend to be great teachers. It is also worth mentioning that most are just as skilled when performing adult anesthesia.

Problem 1: Airway Anatomy is not well understood in EMS
We learn on dummies, dummy. There is a huge disparity between the anatomy of various models and brands. Very few are realistic. Some are terrible. I remember my first intubation manikin, the old Fred the Head. Small wonder that everyone who trained on it thinks the glottis is somewhere halfway between the mouth and toes. Expecting a medic to gain airway expertise from lots of manikin intubations (and a handful of real ones) is just planning for failure.

Suggestion: Take a class and watch a ton of online videos. There are a number of specialty classes for paramedics that will teach you what you didn't get at airway management in school. One is Dr Richard Levitan's AirwayCam course in Baltimore. The biggest I know of is program. They offer difficult airway training for anesthesiologists, ER doctors, and paramedics.

In each course, clinical peers with special expertise will teach you state-of-the-art techniques. You will learn the latest skills and technologies in a program developed by some of the best airway experts in North America.

An offshoot of the program is the new website On you can even watch a video-tour of the airway anatomy, and see the latest video-laryngoscopes in action.

Problem 2: We use blades that are too big
We use blades that are too big under the misguided assumption that bigger is better. This is a huge part of the problem, which came to my attention once disposable blades became popular. Sales reports on disposable blades in both the hospital and EMS markets revealed a distinct pattern. The two most popular blades in anesthesia are the #2 Miller and #3 Mac, but in EMS they are the #3 Miller and #4 Mac.

One of the best adult anesthesiologists in the country is Dr. Allan Reed at Mount Sinai Medical Center in NYC. He uses a #2 Miller on many adults. The most popular blade in the hospital market is a #3 Mac. In EMS we serve the same patients but use bigger blades. In airway management, bigger is not better.

How many Paramedics have ever seen or used the following technique? The paramedics takes a number 3 Miller blade, sticks it all the way in, and then slowly pulls back until the glottis pops into view. Before telling you how bad this is and why, I'll first admit to using it myself in my youth.

What you are doing with this technique is causing trauma to the soft tissue, which can cause swelling and increased difficulty for any subsequent intubation attempts. If you don't get the tube on the first try, you will have a tougher time with the second. The solution is revealed by one category of airway devices, the J-shaped intubation adjuncts.

The most popular of these in EMS is the AirTraq. Other examples included the Pentax Airway Scope from Ambu, and the very first was the Augustine Guide. Its inventor, anesthesiologist Scott Augustine, taught me years ago that it is rarely more than 3" from mouth opening to the vocal cords. Take a close look at all of these J-shaped devices; the forward protruding member on all three is really very short. Yet they were all designed by anesthesiologists and experts in airway anatomy.

The lesson I learned is that less is more when it comes to laryngoscope blade length. By using a shorter blade you risk less damage without impeding visualization in the least. Frankly, it's easier and tends to emphasize finesse as opposed to force.

Suggestion: Whatever your favorite blade style is, try using the next size smaller. This is also a great time to take a hard look at your primary tools of laryngoscopy. Improved models have been developed.

One improvement is LED laryngoscope blades that are very bright. Several are now available as single-use disposables. Another good option is the Grandview Blade from Hartwell Medical.

It is also time to have a plan for when they fail.

Supraglottic rescue airways like the King LTS-D, the LMA Supreme, the Mercury Medical Air-Q, and the Intersurgical I-gel, offer a proven backup for failed intubation. When they should be applied in EMS could be better defined, and next I'll share how.

Problem #3 We have fallen behind the times
The American Society of Anesthesiologists has an accepted national standard algorithm for addressing the problem airway. The ASA Difficult Airway Taskforce publishes updated guidelines to facilitate management and reduce adverse consequences of the difficult airway.

The algorithm they developed (and many workshops the society has sponsored to practice its application) led to greater comfort and timely effective management of the difficult airway whether anticipated or not. The algorithm incorporates all the clinically proven devices and techniques.

We often use outdated airway equipment in EMS. Many use products based on "this is what the hospital gives us," or this was the cheapest online. Very few EMS agencies have invested in video-laryngoscopy. Many don't even have bougies or good rescue airways yet. We have a thousand dollar light bar on the roof and a "black-box" under the floor, but rely on the cheapest blade we can buy?

Suggestion: Why don't we develop our own national practice guidelines for the difficult airway? They would of course be a little different then the ASA's, due to scope-of-practice limitations and technology. For example, we won't likely have a flexible fiber optic bronchoscope available on an ambulance anytime soon, but I bet the folks at the ASA would be glad to help us do it.

We should not accept second-rate EMS care for ABC type emergencies. We should all be experts in airway management, breathing support, and circulatory support. It should be hard to find somebody better than a medic at putting in breathing tubes or plugging in IV lines. We should have the skills and training PLUS the right equipment to deliver these core support therapies under any conditions, without compromise.


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