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The Airway Manifesto- Part 1: Clean Kill

Airway management is NOT about passing a piece of plastic between the vocal cords.

We can fool ourselves and get a clean kill with a laryngoscope if we fail to recognize the need to actively provide resuscitation throughout the procedure. No one ever died because they didn’t have a piece of plastic shoved down their throat. Patients die because they’re not oxygenating or perfusing. An endotracheal tube is simply a conduit to provide a God given physiological function. Patients die because we allow them to become hypotensive, hypoxic, and aspirate before, during, and after our intubation attempts. There is tunnel vision and bravado associated with managing the airway. We must address to stop killing our patients.

The fields of Emergency Medicine and Paramedicine were born out of individuals contributing their best tid bits of knowledge from a variety of fields. While this can be an efficient way to practice medicine, it can be dangerous because we miss some of the nuances of their situation involved in specialized care. Instead of ending up with Jambalaya, we ended up with porridge. Porridge will keep you alive, but is unlikely to make you thrive. This is especially true with airway management.

We took the lessons learned from other specialties, and added our own flavor to it and fracked it up even more. Take for instance the sniffing position - the sniffing position is the position to sniff a flower (or sip from a full beer). We can take the Tragus to Vegas and ramp the patient to place them in the true sniffing position.

The sniffing position is often incorrectly used to describe the hyper-extended position, the position often taught to place the patient in to intubate. The hyperextended position is the position sword swallowers use, which easily allows the sword to be placed down the esophagus. The fields of Emergency and Paramedicine must be able to systematically, intentionally, and efficiently adapt and address emergency airway management with the evidence-based medicine currently available and applicable emergencies.

Anesthesia provides a long history and support for management of the both good and difficult airways. Unfortunately these strategies are not meant for application with acute, emergent airways. Emergency Medicine and Paramedicine must be able to provide more research and foundation for managing emergent airway scenarios. Out-of-hospital clinicians must also be cognizant that your specialty has unique elements and that not everything the Emergency Department or ICU does, will work or has applicability in the field. Luckily industry leaders are beginning to provide research that is conducted and applicable to Emergency and Paramedicine.

Dr. Jeff Jarvis and his companions performed a retrospective, before and after study on non-cardiac arrest intubations in a suburban EMS system. Williamson County EMS is a pretty progressive EMS system being led by a pretty solid medical director. They’re an A Team, this is no place for shlack’n off. One of their previous studies showed a dramatic increase in First Pass Success utilizing the King Vision and have gone exclusively to utilizing VL for all intubations. Throughout the study they also had initial and yearly competence testing along with monthly trainings.

The before section, the blue lines on the left, were patients who the paramedic was encouraged to preoxygenate with an NRB or NC under a BVM then performed a standard RSI with ketamine immediately followed by hitting them with the Sux (succinylcholine) or Rock (rocuronium). This process is common across many EMS systems and Emergency Departments. What happens? Hypoxia, one of the three killers in airway management. With this common practice the patient’s SpO2 drops an average of 44%. Hypoxia kills.

For the after section they implemented a clinical bundle. These paramedics were required to completely disassociate patients with ketamine followed by flush rate O2 via NC under a BVM with a PEEP Valve after they took the Tragus to Vegas by placing the patients in the ear to sternal notch position. A second paramedic ensured that for at least 3 minutes they maintained a SpO2 greater than or equal to 94%. At any time the SpO2 dropped below the 94% mark the timer would restart. They were then paralyzed by rocuronium and intubated. This time the SpO2 drop an average of 3.5%.

This study did not look at outcomes, but know that hypoxia kills patients. We certainly are not helping our patients by utilizing a standard RSI strategy and are likely to get a clean kill if you are not intentional and methodical about an approach to the emergent airway. Emergency Medicine and Paramedicine must do better.

The optimal airway management strategy is an integration of knowledge and skills to provide appropriate interventions to resuscitate a patient. The foundation of optimal airway management is the capability of human performance to provide favorable patient outcomes supported by the technical skills to perform airway management. The goal of optimal airway management is to improve oxygenation and perfusion through appropriate ventilation in a timely manner that improves outcomes and decreases clinical variation.

To improve outcomes, we need to:

  • Put the ego aside

We need to keep in mind that we’re treating people. Our patients don’t care whether there was a piece of plastic between their vocal cords. Patients want a passionate and caring clinician who makes them better than when they came in.

  • Embrace human factors

Humans are complex creatures who have an amygdala, adrenal glands, and prefrontal cortex’s that do illogical things, because of heuristics, biases, stress, ego, fatigue and other unrealized factors. We need to understand the capabilities of human performance and design systems that optimize our performance.

  • Create a system to adapt to change

Utilize peer quality assurance in a timely fashion that is overseen by a medical director. Utilize current data to identify strengthens and weakness of your practice. Meet on a weekly basis to discuss good and bad cases and how we can apply field-oriented research to improve or change our practices.

  • Research!

Plain and simple, there is an epidemic of poor education, development, and patient care delivered by a paramedic. A lot of patients aren’t being treated adequately because we don’t created a solid foundation of knowledge. I feel that the industry really wants to be the change. There is a deep burning passion by EMS providers to be better. The clinicians are hungry. Leadership, medical directors, and educators need to be just as hungry to create education, that utilizes evidence-based medicine to provide better health and better care at a lower cost. We need to produce research that is EMS specific instead of extrapolating what happens in the ICU and OR. EMS is outside the four wall of the hospital, they're different environments with unique characteristics that change how we practice.

  • Utilize an approach to prevent hypotension, hypoxia, and aspiration

Create a checklist, use SALAD, and resuscitate before you intubate. Patients may survive the procedure, but it doesn’t mean they’ll walk out of the hospital. Create and utilize tools, bundles and practice standards to prevent hypotension, hypoxia, and aspiration.

  • Be ready and able to cut

Every time you manage the airway you should be ready and capable of performing a cricothyrotomy. Have a plan and move to the next step in the plan with poise and intentionality.

  • ALWAYS use waveform capnography

Plain and simple there should not be any breath administered through an endotracheal tube or supraglottic airway without waveform capnography on it. Stop making excuses and do the best thing for the patient.

  • Embrace advances in practice

An ET tube may not be the best thing for the patient, but sometimes it is. If you’re going to intubate, be the best. Use a video laryngoscope every intubation. If you utilize direct laryngoscope than have the data to back it up that DL is superior to VL in your system. That laryngoscope should be an extension to your body, a tool that you have mastered. Learn when you should bag, tube, place an SGA, and cut.

The Airway Manifesto will challenge the current standards of care to provoke, change, and foster commitment to be an airway master. Never again should medical professionals kill Drew Hughes. Never again should medical professionals kill Elaine Bromiley. We can do better and our patients deserve the best clinician every. single. time. Each of us are capable of providing excellent care people, let’s create the system to make it happen.

-Adam LaChappelle (@vamedic on Twitter)

The master of disaster looking to practice good medicine in austere environments

Post note:

The Airway Manifesto is far from complete. I don’t have all the answers and hope to pull together swath of passionate providers to weigh in. This is the beginning of a series that will be published until complete. Together we’ll do better.


Comparison of Paramedic First Pass Endotracheal Intubation Success Rate of the VividTrac VT-A 100, GlideScope Ranger, and Direct Laryngoscopy Under Simulated Prehospital Cervical Spinal Immobilization Conditions in a Cadaveric Model. Prehospital and Disaster Medicine, 32(6), 621–624.

Jarvis, J. L., Gonzales, J., Johns, D., & Sager, L. (2018). Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia. Annals of Emergency Medicine, 72(3), 272-279.e1.

Jarvis, J. L., McClure, S. F., & Johns, D. (2015). EMS Intubation Improves with King Vision Video Laryngoscopy. Prehospital Emergency Care: Official Journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 19(4), 482–489.

Kovacs, G., Lauria, M., Law, J., & Croskerry, P. (n.d.). Human Factors and Resuscitation Psychology in Airway Management. In Airway Management in Emergencies (3rd ed.).

Murphy, D. L., Rea, T. D., McCoy, A. M., Sayre, M. R., Fahrenbruch, C. E., Yin, L., … Mitchell, S. H. (2019). Inclined position is associated with improved first pass success and laryngoscopic view in prehospital endotracheal intubations. The American Journal of Emergency Medicine, 37(5), 937–941.

Savino, P. B., Reichelderfer, S., Mercer, M. P., Wang, R. C., & Sporer, K. A. (2017). Direct Versus Video Laryngoscopy for Prehospital Intubation: A Systematic Review and Meta-analysis. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine, 24(8), 1018–1026.

Weingart, S. D., & Levitan, R. M. (2012). Preoxygenation and prevention of desaturation during emergency airway management. Annals of Emergency Medicine, 59(3), 165-175.e1.


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