Did you make it to the 2011 EMS Today Conference & Exposition? What a great experience! I had the honor to moderate a panel discussion titled “Should We Intubate?” Four great panelists and about 200 folks in the audience resulted in lively debates and a challenge to be great EMS providers. As the moderator, I really didn’t get the chance to stand on my soapbox, so I’ll take that opportunity now.
Why does the thought of taking endotracheal intubation out of the hands of paramedics invoke such a visceral response? I didn’t whine when the EOA left. No heartburn when I put MAST back on the shelf. What is it about an ET tube? Because for decades, it’s all we had.
Endotracheal intubation via direct laryngoscopy has been used since the late 1800s.1 Numerous BLS airways were developed during World War II. Extraglottic airways appeared in our airway kits in the early 1980s.2 Flexible and rigid fiber optic laryngoscopes made their way into operating rooms in the early 1990s. It wasn’t until the turn of the century that laryngoscopy changed for EMS with the development of video laryngoscopes.
For about 110 years, direct laryngoscopy has been THE method to place an endotracheal tube. In EMS, we’ve relied on this method for about 40 years (depending on how you write the timeline). We reinforce the dogma that the endotracheal tube is the airway of choice by referring to all other devices as “rescue airways.”
So I ask the question: Should we intubate? When it’s appropriate, absolutely. The endotracheal tube is a wonderful tool that has been successfully placed and managed for decades outside of the operating room. It continues to be used successfully by EMS professionals on a daily basis.
I’ve read a ream of studies professing the evils of prehospital endotracheal intubation. While there are descriptions of hypoxemia and trauma during endotracheal tube placement, the vast majority of the described evils come from what is done after the tube is placed; hyperventilation, hypocarbia, unrecognized misplaced tubes and reduction of blood return to central circulation.
Wait a minute; can’t those same evils occur with extraglottic airway devices or even a bag-valve mask? Why yes, they can. You can also add gastric distention, vomiting and reduced tidal volume to the BVM list. We have to do a great job managing any airway device.
As technology has progressed, we’ve been given fantastic new tools to help us do a better job. We’ve all seen studies that show the effectiveness of end-tidal carbon dioxide monitoring to verify tube placement and appropriately ventilate. Since 2003, studies from hospital and EMS settings have published results of the use of video laryngoscopy; shorter intubation times than direct laryngoscopy, high first pass success rates, and Grade I–II views with poor neck mobility.3-5 The gum elastic bougie, (and its plastic alternatives) is such a simple and incredibly effective tool, it should be mandatory in every airway kit. I’m quite sure you can list several other items. Proven technology must be embraced as the standard of care for our patients.
So, I ask: Should you intubate? It’s entirely up to you. Are you willing to use the tool that best fits the patient, the conditions and your abilities? Are you willing to do what it takes to be a professional airway manager?
I’ll leave you with the challenge leveled at the end of the panel discussion. All of us must drive to excel as medical professionals, to refuse to accept mediocrity as a level of care and to simply do the very best for our patients.
I’m excited and humbled at the opportunity to provide information that will help all of us become better airway managers. I look forward to hearing from you.
Until next time, take care and be safe.
- Bailey B (1996). “Laryngoscopy and laryngoscopes–who’s first?: The forefathers/four fathers of laryngology.” The Laryngoscope. 106(8):939–943, 1996.
- Donmichael TA. US Patent 4497318, Feb. 5, 1985.
- Agro F, Barzoi G, Montecchia F. “Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization.” Br J Anaesth. 90(5):705–706, 2003.
- Nouruzi-Sedeh P, Schumann M, Groeben H. “Laryngoscopy via Macintosh blade versus GlideScope: success rate and time for endotracheal intubation in untrained medical personnel.” Anesthesiology. 110(1):32–37, 2009.
- Cormack RS & Lehane J. “Difficult tracheal intubation in obstetrics.” Anaesthesia 39(11):1105–1111, 1984.
EOA = Esophageal obturator airway
MAST = medical anti-shock trousers
BVM = bag-valve mask