of mannequins, simulators, cadavers, and live patients [69]. One older study suggests that paramedic students need at least 20 to 25 live ETI encounters in the operating room, hospital, or prehospital setting to attain baseline ETI proficiency [70]. Most successful prehospital airway management programs require EMS personnel to perform more than five ETIs annually. These programs have access to operating rooms to provide supplemental training. While experience gained through field intubations is optimal, EMS personnel perform surprisingly few airway management cases in clincial practice. In many cases, paramedics may perform ETI less than once per year.
Whenever possible, the medical director should seek opportunities for EMS pracitioners to obtain live patient intubation experience. Ideally this would be done in operating rooms and EDs under close supervision. Contracts and memorada of understanding may help limit medicolegal exposure, define expectations, and improve access to procedures. Cadaveric training may also be useful, providing some of the variability and context of a live intubation while limiting risk. Access to cadavers for intuabtion training, however, is limited and costly.
Many training programs and EMS agencies use mannequins and human simulators for ETI training [71]. Simulators do not accurately recreate the “feel,” range, or variability of live human airway anatomy. However, simulators are convenient, widely available, flexible, and can be relatively less expensive than other adjuncts for airway training. Low‐fidelity human simulators, which often consist of just a mannequin head, are useful for limited psychomotor training. Some EMS medical directors advocate integrating high‐fidelity human simulator‐based training to recreate complex “difficult airway” situations [37]. The rationale for this additional training is to develop airway management decision‐making skills, which cannot be fostered in the controlled operating room setting. It is essential that paramedics develop good airway management decision‐making skills, not just good laryngoscopy skills.
Airway management protocol development and equipment selection
Airway management protocols may include several components. They are inclusion and exclusion criteria, an airway management algorithm, descriptions of mandatory procedures, benchmarks for quality assurance, and parameters for difficult or failed management. Protocols should clearly delineate inclusion and exclusion criteria based on physiological parameters, which indicate failure of ventilation or oxygenation. These may include vital sings (including respiratory rate, oxygen saturation, end‐tidal carbon dioxide), respiratory mechanics (fatigue, accessory muscle use), and mental status (Glasgow Coma Scale). An airway management algorithm needs to be specific to the equipment and skills available within the system.
One example of a structured airway management algorithm is shown in Figure 2.1 [72].
How to proceed through the airway algorithm is often a matter of judgment. Furthermore, EMS clinicians may have to alter the response to the algorithm based on patient (lack of reserve) or scene (unsafe environment) conditions. Clinician judgment can be improved through case review of errors and best practices, as well as practice with high‐fidelity simulation [73, 74]. Key among these skills is the ability to recognize a difficult airway and plan contingencies for a difficult or failed airway. Given the challenges inherent in prehospital airway management it may be prudent to anticipate all prehospital airways as difficult.
Figure 2.1 Airway management algorithm. Source: Wang HE, Kupas DF, Greenwood MJ, et al. An algorithmic approach to prehospital airway management. Prehosp Emerg Care. 2005; 9:145–55.
Quality management
For airway management, quality managment begins with initial training and skills verification, ensuring that each clinician can perform airway management skills for his or her level of training. EMS clinicians should then be educated on the application of those skills in simulation and scenario‐based education. Skills maintenance should occur at regular intervals for all personnel with special attention to clinicians who have been unsuccessful in field airway management or who have not had the opportunity to manage airways in the field.
If possible, all airway management cases should be reviewed with special emphasis placed on instances of failed airway, misplaced or dislodged invasive airway devices, number of attempts, and exposure to hypoxia, hypotension, hypo/hypercarbia, and death. Continuous physiological data are now commonly available with all portable cardiac monitors and should be reviewed for each airway case. Case review requires the reliable abstraction of pertinent data elements as described in the National Association of EMS Physicians position statement on recommended guidelines for uniform reporting of data for out‐of‐hospital intubation [75]. The Ground Air Medical qUality Transport (GAMUT) quality improvement collaborative proposes measuring definitive airway management sans hypoxia/hypotension on first attempt (DASH‐1A) as the fraction of advanced airways placed on the first attempt without SpO2 <90% or systolic blood pressure <90 mmHg [76]. When available, quality data should also include time to intubation and review of video images time locked to physiological data to address issues of technique and mitigation of patient exposure to hypoxia and hypotension.
Review of airway cases should be used to inform directed feedback to the clinician, assessment of system processes that may have contributed to error, and future continuing education so that all personnel can learn from any errors. Directed clinician feedback may include case review, skill reassessment, or additional scenario‐based training. System‐based assessment should allow the medical director to examine the protocols and procedures asking the question, “Would other EMS clinicians perform similarly in the same situation?” In rare cases, it may be necessary to send an immediate system‐wide message out to prevent such a problem from recurring. Lastly, in order to improve system‐wide performance, incorporation of challenges into simulation or scenario‐based training will allow others to learn from adverese events in a safe environment.
Research
While there have been recent significant advances in airway management science, many important unanswered questions remain. In seeking new knowledge, it is important to recognize that retrospective observational data of prehospital airway management are all vulnerable to confounding by indication. Randomized controlled trial designs are necessary to result in the most accurate observations.
While informed by many observational series, the optimal approach to prehospital trauma airway management remains unclear [9]. An objective of prehospital airway management is to enable optimized ventilation. However, there have been few rigorous studies of prehospital ventilatory techniques. Davis, et al. observed that hyperventilation is common after prehospital RSI of traumatic brain injured patients and associated with worsened outcomes [46]. A before‐after study in Arizona suggested that avoidance of hypoxia, hyperventilation, and hypotension were important in optimizing traumatic brain injury outcomes [77]. The field requires additional study of ventilation strategies and mitigation of secondary injury.
Critical decision making: an illustrative vignette
Paramedics are dispatched to a patient with respiratory distress who is noted to have swelling and pain involving the submental tissues that began within the last 24 hours. He has been suffering from a tooth infection and was recently placed on penicillin and advised to see a dentist for an extraction. The crew arrives to find the gentleman with trismus and drooling. His vital signs are BP 136/84 mmHg, pulse 110/min, RR 26/min, SpO2 97% on room air. The EMS clinicians assess the patient’s airway and elect to perform RSI. They are concerned that he will not be able to protect his airway for the
