Tips For The Occasional Intubator

Let’s face it, as paramedics, we don’t walk around every shift throwing a tube down everyone’s throat! We have to realize that this is a skill that has the potential to save someone’s life but also has the potential to take one. There have been rumblings back and forth on whether medics should be allowed to perform a skill they don’t use frequently. These arguments are backed by scenarios where providers have failed intubation, intubated the goose, and never used any quantifiable markers to validate placement….. and the patient died.

Can we honestly use this as an argument to take away the skill of endotracheal intubation at the Paramedic level?

Let’s address this question with some very reasonable concerns that come up regarding airway management training in Paramedic schools.

With so much to cover in a short period of time, airway management does not get NEAR the time it deserves in our initial education. We are taught that an RSI is a lighting speed process, we are told to hold our breath, and when we need to breathe, it’s time to get out! We believe we will dip the blade into the hypopharynx and immediately see the cords!! These teachings create a nervous and jittery intubator who isn’t breathing because some yahoo told him to hold his breath!

Their competency is validated by the ability to perform five intubations in a nicely lit, controlled environment. Under the heuristics and proper setup of an anesthesiologist.

So now you are probably wondering… where are the tips? This just seems like a dig at formal paramedic education! The first tip is to realize that you are an “occasional intubator.” Don’t let that discourage you because you can achieve excellence with this skill; you just need to put all the odds in your favor.

Tip 1. Positioning

99% of the time in school, you will be intubating mannequin heads that are stuck to a flat board. You will find yourself bending down low and trying to get eye level with the larynx axis. Fingertips turn white as you struggle to lift forward enough to see the cords while trying not to use the teeth as a fulcrum. There are three-axis we need to become familiar with when intubating. The oral, pharyngeal, and laryngeal axis. These can easily be aligned by putting the patient in an ear to sternal notch position. When applied properly, you really only need the laryngoscope to lift the tongue out of the way.

This technique, in cooperation with airway adjuncts, also helps optimize First Pass Ventilation (FPV) with a BVM. The saying “work smarter, not harder” applies simply to how you position your patient.

Tip 2. Delay Your Sequence

Intubation is not a game of speed. Get scene times out of your head for a minute and realize that speed means nothing when you deliver a hypoxic patient in peri-arrest. Delayed Sequence Intubation (DSI) is procedural sedation, with the procedure being pre-oxygenation. If you are intubating a hypoxic patient, you are setting yourself up for failure. Take the time to properly pre-oxygenate & denitrogenate your patient. This usually takes about 3 minutes to perform…. Can you wait that long? It may seem like FOREVER, but trust me, it will give you a safety net during intubation. The goal of the peri-intubation period is to have the patient spontaneously breathe as much as possible until the point of intubation. This prevents excessive bagging, gastric insufflation, and some negative effects of BVM ventilation. Most induction agents, such as versed, etomidate, and fentanyl, will depress your respiratory drive. So how do we keep this breathing adequately until the point of intubation? There are two answers…

1. Dissociative dosing of ketamine allows the patient to maintain normal airway drive and reflexes. This is why it has commonly become the drug of choice for DSI.

2. Timing principle induction is the concept of pushing your paralytic first since you know it will take approx. 60 seconds or longer to kick in, and following shortly after with your sedative. This allows the patient to breathe up until the point of paralysis spontaneously. This idea has been around since the 90’s but was recently brought up in an article by EMCRIT’S Josh Farkas.

Tip 3. NoDesat

“Nasal Oxygen During Efforts To Secure a Tube” (NODESAT) is a term coined by Rich Levitan in regards to placing a nasal cannula at high flow on a patient during the pre-ox and intubation process. This allows not only augmentation of FI02 from a NRB or BVM, but also the ability to provide apneic oxygenation during intubation. The idea is during the pre-ox period you place a NC at 15lpm, a NRB at 15lpm, and try to achieve an SP02 of 100 % for at least 3 minutes prior to intubation. Because this provides little positive pressure, it will likely not work in a patient with physiological shunting. If you HAVE to ventilate a patient due to inadequate peri-intubation ventilation, then the use of CPAP or BVM with a PEEP valve will be needed. By utilizing Henry’s law we can not only increase the surface area of alveoli by recruitment but also apply pressure to the oxygen to assist in diffusion.

Tip 4. Ditch The Stylet!

Some may crucify me for saying this, but statistics and anecdotal experience has shown you are much more likely to achieve first pass success if you utilize a bougie. The old way that we were taught to use the bougie required two people to perform. One person would intubate the trachea with the bougie, and the other would assist in railroading an ET tube over the bougie. A more common and efficient trick in the pre-hospital realm, is to preload the bougie with either a Kiwi grip or D grip. The cudae tip allows for easier anterior access, and the tactile feel of the bougie allows you to feel the tracheal rings upon successful placement. The bougie is commonly used as an emergency tool for difficult airways. If we are intubating a patient, it is an emergency, and we need to use everything possible to optimize our FPS. The occasional intubator recognizes the need to utilize every strategy possible to achieve their goal. A study showed providers increased their FPC success rates from 66% to 96% just by utilizing the bougie. This is a must in every pre-hospital airway kit.

Tip 5. Video Games

It’s no doubt that video laryngoscopy (VL) is sweeping the nation. While there are some resistors, most providers have moved towards utilizing VL for their routine intubations. The VL tool comes in many shapes and sizes, and each one provides a little something different. Hyper-angulated blades allow you to “peak” around the corner with little tissue displacement. The standard geometry blade allows you to use tools like DL but optimize your view and allow your colleagues to see what you see. For these reasons, I have personally adopted VL into my routine practice. I have seen the success rates of my service DRASTICALLY improve with this addition. I have seen some studies that show no difference between DL & VL. My only argument against these studies is that the services that are cooperating in the study have high exposure to intubations. The question isn’t whether VL is better than DL, but rather are we practiced enough to use DL effectively.

Tip 6. Simulation

“The mannequin is nothing like the real thing!” This phrase comes out of most student’s mouths as they walk out of the operating room after clinical. The truth is, they’re right! But, I don’t think the actual procedure of intubating is that difficult, and it’s certainly not the most dangerous. The part that we need to practice is the steps leading up to intubation and the monitoring afterward. No one dies from someone missing a tube and recognizing it right away. People die when the heuristics and planning fail to recognize failure. Guess what? This part we can simulate! Students routinely go into the OR and nail intubation under the proper setup of an anesthesiologist. It’s required to complete clinicals! This right here tells me that we are capable of performing the skill; we just need help with knowing when to do it, and optimizing the conditions we perform it in.

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