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The Great Airway Debate

3 EMS physicians highlight the challenges that prevent a consensus on endotracheal intubation across EMS systems and the importance of case review


Three well-known experts took to the stage at the National Association of EMS Physicians (NAEMSP) Annual Meeting to summarize recent research and advocate for and against paramedic endotracheal intubation

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SAN DIEGO — The National Association of EMS Physicians (NAEMSP) Annual Meeting didn’t shy away from one of the hottest topics in EMS: advanced airway management by prehospital providers. In fact, on Day 1, three well-known experts took to the stage to summarize recent research and advocate for and against paramedic endotracheal intubation.

Henry Wang, MD, MS, professor and executive vice-chair of research of the University of Texas’s Department of Emergency Medicine, started things off with a nice summary of the literature to date, acknowledging that paramedic intubation has been standard practice in the prehospital setting for over 40 years. On the negative end, he focused on the following pitfalls that have been documented concurrent to paramedic intubation attempts:

  • Unrecognized esophageal intubations
  • The need for multiple attempts
  • Hyperventilation and interruption in chest compressions during OHCA
  • The limited training and clinical exposure providers receive

Dr. Wang then reviewed three landmark clinical trials:

  1. The PART Trial randomized OHCA patients across various ROC sites to either a laryngeal tube or traditional endotracheal intubation. The trial was only powered for 72-hour survival, but the laryngeal tube reigned supreme.
  2. The AIRWAYS 2 Trial randomized paramedics in the United Kingdom to endotracheal intubation or a supraglottic airway device while treating patients during OHCA. There was no difference in neurological status at discharge found between the groups.
  3. The CAAM Trial randomized OHCA patients in France and Belgium to endotracheal intubation or bag-valve mask ventilation. There was no difference in 28-day survival.

Next, Milwaukee County’s Riccardo Colella, DO, MPH, FACEP, division chief, EMS Medicine, Medical College of Wisconsin; and State of Wisconsin EMS medical and trauma director, explained why his system leaned into a laryngeal tube-only approach after the completion of the PART Trial. Dr. Colella described four main drivers for their switch:

  1. There are over 500 paramedics in the county, and that number is only increasing.
  2. There are a limited number of endotracheal intubation attempts. With only 1,050 OHCA per year and no hospitals willing to share operating room time, paramedics can graduate without ever having intubated a real patient.
  3. The historical performance data suggested paramedics were disproportionately opting into laryngeal tube when expecting a difficult airway. Additionally, the system allows EMTs to insert the laryngeal tube, which, once in place, was rarely replaced with an endotracheal tube.
  4. Being a fire-based EMS system limits training opportunities. Paramedics must not only receive continuing medical education, but also must keep up to date on their fire ground skills.

Seattle Fire Department’s Michael Sayre, MD, medical director for Seattle Medic One, a physician in the emergency department at Harborview Medical Center and a University of Washington professor of emergency medicine, finished things off by describing the extensive exposure Seattle’s intensive care paramedics get to patients requiring advanced airway management. First, he shared research that the median emergency physician intubates 10 times per year, which is one less patient than the median SFD paramedic intubates annually. Second, he showed that nearly all OHCAs treated by paramedics are eventually intubated, and only 1-in-6 cases require a stop in chest compressions in order to intubate.

Next, Dr. Sayre explained that the intuitive relationship between higher first-pass success rate and more frequent Grade 1 views is also present within his data. He highlighted that there is individual disparity in the system, and that he plans on interviewing the high performers to better understand what they are doing differently before generalizing those learnings to the larger workforce.

The panel then ended with a Q&A session, although it was obvious there was no clear winner on the debate stage.

Memorable quotes on advanced airway management

Here were some quotes that stood out:

  • “Recent media reports suggest that the unrecognized esophageal placement epidemic still is very much real.” — Henry Wang
  • “If you want to become a wildly unpopular medical director, I would suggest considering moving or altering the practice of intubation ... it does not go over well.” — Riccardo Colella
  • “Great training and experience with feedback are the keys to success, and careful measurement exposes these training opportunities.” — Michael Sayre

Key takeaways on the airway management debate

Here are my top three takeaways from the presentation on airway management strategies.

1. This debate isn’t going anywhere

Given the lack of consensus from three EMS physicians, it should be obvious that as an industry, this debate isn’t settled. Different systems have different constraints, something that was easily highlighted by the simple comparison of the number of opportunities to intubate paramedics in Milwaukee County have versus those in Seattle.

2. Intubation requires the interrogation of data

The decision to intubate should not be taken lightly, just as the decision to allow intubation to continue should be made under the auspices of up-to-date science and a continuous review process. I applaud Milwaukee County’s decision to remove endotracheal tubes from their paramedic scope of practice after a thoughtful review of their data and system capacity.

3. Advanced airway management case review is the new normal

Much as cardiac arrest case review has become the norm for any high-functioning EMS system, agencies that review all attempts at advanced airway management are only becoming more prevalent. Just as providers should be required to use waveform capnography to confirm tube placement, medical directors and quality improvement officers should use case review to confirm appropriate airway management in the prehospital setting.

Additional resources on airway management

Learn more about how EMS airway management is evolving with these resources from EMS1:

Catherine R. Counts, PHD, MHA, is a health services researcher with Seattle Medic One in the Division of Emergency Medicine at the University of Washington School of Medicine. She received both her PhD and MHA from Tulane University School of Public Health and Tropical Medicine.

Dr. Counts has research interests in domestic healthcare policy, quality, patient safety, organizational theory and culture, and pre-hospital emergency medicine. She is a member of the National Association of EMS Physicians and AcademyHealth. In her free time she trains Bruno, her USAR canine.

Connect with her on Twitter, Facebook, or her website, or reach out via email at