for video laryngoscopy
While offering improved laryngscopic view, intubation success, and time to tracheal intubation, video laryngoscopy is not a replacement for direct laryngoscopy skills or training [48, 49]. Complications associated with video laryngoscopy are similar to those for traditional intubation, including multiple intubation attempts, exposure to hypoxia and hypotension, and airway perforation [50]. In addition, practitioners must be familiar with the techniques particular to individual video devices.
If video laryngoscopy is employed, the EMS medical director must also decide whether it is used as the primary intubation method, which may erode skills associated with direct laryngoscopy, or if it is used as a rescue technique. Cost is also a factor, as many of these devices cost several thousands of dollars to acquire and maintain. If the number of airway interventions in the service is low, the EMS medical director may consider applying those resources to training or more frequently used equipment.
Considerations for SGA
SGAs may be used as primary airway management tools, or as rescue devices for failed ETI [51, 52]. SGAs are generally easier to insert and have greater success rates than surgical airway techniques, especially in situations potentially involving difficult airway anatomy. National consensus guidelines recommend that all EMS personnel carry at least one type of SGA (e.g., laryngeal tube, i‐gel, or Laryngeal Mask Airway™) for airway management in the event of failed ETI efforts [53].
The 2015 Advanced Cardiac Life Support guidelines emphasize the delivery of uninterupted chest compressions during CPR [54]. Embracing this principle, a growing number of EMS agencies have elected to substitute ETI with the rapid insertion of an SGA in patients suffering cardiopulmonary arrest [55, 56]. Benefits of using SGAs as the primary invasive airway device may include the simplicity of operation, the reduced risk of significant adverse events (such as inadvertent airway dislodgement), and the reduced baseline and skills maintenance burdens. Additionally, SGA insertion skills may be more easily translated from mannequin training to clinical application on live patients. Limited data verify the ablity of EMS personnel to place SGAs during cardiac arrest in less time than an endotracheal tube [13].
Some EMS agencies enable BLS clinicians to insert SGAs. Previous studies have demonstrated the use of SGAs in this group with a high degree of success [31, 57]. First‐pass success appears higher with SGA than ETI [12, 13]. BLS use of SGAs outside of cardiac arrest has not been studied.
Considerations for surgical airways
Prehospital sugical airway procedural success is highly variable, ranging from 17% to 93% [58–61]. Survival after perhospital surgical airway placement is poor, ranging from 15% to 37%. Limited data describe the complications associated with prehospital cricothyrotomy [62–65]. Some medical directors question the role of cricothyrotomy in the prehospital setting, citing the difficulty of the procedure and the rarity of the intervention with associated need to maintain appropriate clinical skills.
Considerations in pediatric airway management
The clinical trial reported by Gausche et al. demonstrated no survival or neurological benefit from prehospital pediatric ETI [10]. Given the strength of these data and the relatively low number of pediatric procedures performed by individual prehospital clincians, some EMS physicians recommend BVM ventilation instead of ETI for critically ill children. Others have dismissed the generalizability of the study. Consequently, prehospital pediatric airway management practices vary across the United States.
Pediatric airways have unique features that may present difficulties for those not accustomed to caring for critically ill children. Since pediatric patients comprise a small proportion of all prehospital ETI, EMS medical directors must weigh the benefits of pediatric ETI against the challenges of providing adequate pediatric airway training and clinical experience. SGA are now available for children. Given broad SGA success in adults, the availability of SGA for children provides an important additional option for prehospital personnel. Pilot and simulator series describe the viability of SGA use in children [66, 67].
Who should manage the airway?
The degree to which EMS clinicians participate in airway management is determined by their scope of practice and the discretion of their medical directors. EMS protocols for airway management may vary based on the qualifications of available personnel and the system architecture. While all clinicians should be adept at basic airway management, invasive airway management may be limited to advanced personnel. The EMS medical director must choose which clinicians receive advanced airway training, taking into account the ability to acquire and maintain airway skills, as well as distance to the hospital and the availability of backup personnel.
Tiered response systems may offer options for organizing airway management. The additional clinician may be a supervisor or a more experienced person capable of a wider range of airway management techniques. For example, some systems limit RSI to supervisor units. Limiting ETI to supervisors or a specific cohort of clinicians has the benefit of concentrating field experience for the procedure and decreasing the resources necessary for training and competency verification. The ideal airway management paradigm for a given service may vary based on the qualifications of EMS clinicians, available resources, coverage area, and volume of calls requiring airway management.
Clinician training and competency
ETI is a complex and difficult procedure, and substantial training is required to attain and maintain proficiency. EMS clinician training requires three components: baseline acquisition of skill, maintenance of skill, and an iterative process of quality management used to identify deficits and guide skills maintenance. EMS agencies universally struggle to provide adequate airway management training.
EMS clinician competency requires a program of initial training followed by periodic skill verification and continuing education. Training should begin with didactics to review basic airway management. Advanced airway procedures should be introduced by discussing indications and contraindications for airway management, an algorithm for airway management, procedural complications, relevant pharmacology, local protocols, and special considerations.
Psychomotor skills should also be taught and verified using a model or low‐fidelity simulator. Skills reviewed should include all the skills necessary for the airway management algorithm, including identification of the indications for airway management, BLS airway skills, invasive airways, and surgical airways when applicable. High‐fidelity simulators may provide added realism for teaching psychomotor skills and also provide the ability to run scenarios to test decision making and practice the procedures needed to move through the airway management algorithm. High‐fidelity simulators can also be used to assess protocol knowledge, teamwork dynamics, and adherence to policies.
Obtaining live intubation training in the operating room or other controlled environment is the criterion standard of airway training. However, access to operating rooms is often limited by availability, liability, and cost [68]. The prevalence of noninvasive forms of airway management in the operating room combined with an increase in the number of trainees and professionals seeking intubation experience (residents, nurse anesthetists, respiratory therapists, etc.) has reduced the opportunity for prehospital clinicians to obtain ETI experience in controlled environments. Furthermore, selection bias introduced by the supervising professional may limit the trainee to only less‐challenging airways. Liability concerns have further curtailed intubation experiences for EMS clinicians.
The optimal number of encounters for maintaining prehsoptial ETI skill is unclear. Current educational guidelines advocate that paramedic students undergo at least
