If you鈥檙e an EMS provider preparing to intubate, you know a few things about your situation. One, your patient is in dangerous shape, with an airway that鈥檚 compromised or in imminent peril. Two, other methods of airway management have failed or aren鈥檛 viable, necessitating an invasive option that can be difficult even under pristine circumstances. And three, you鈥檇 better get it right the first time.
That鈥檚 a troubling trifecta of challenges to face. Intubation in the field has higher rates of complication and failure than in the hospital,1 and requiring more than one attempt to place an endotracheal tube can have negative consequences for your patient.2鈥�5
What makes this important intervention so difficult, and what can providers do to accomplish it more easily and successfully?
THE FIELD CAN BE UNFORGIVING
Whether you work in a hospital or the field, many of the factors that make endotracheal intubation and its preceding step, laryngoscopy, difficult are the same.
Among patients that can include age, size, physical status, anatomy and hemodynamic stability. Prehospital providers may also have to contend with questions of access, location, positioning and illumination.
Among providers, factors can include training, technique, experience, skill and knowledge. They can also be bound by differences in devices, techniques and medications.
鈥淭here are several red flags that can potentially alert both anesthesia and EMS providers that an airway may be difficult,鈥� said Patrick Shay, a certified registered nurse anesthetist from Pennsylvania who鈥檚 also spent 36 years in EMS. 鈥淲hen we look at any patient for an anesthetic, a procedure or even an emergent intubation, we have to take a few seconds to actually look at their physical anatomy and evaluate those red flags.鈥�
EMS providers of course have the popular LEMON mnemonic 鈥� representing look externally, evaluate (3-3-2 rule), Mallampati score, obstructed airway and neck mobility 鈥� to help predict difficult airways,6 as well as other methods.7 Beyond that, they may anticipate laryngoscopy difficulty when patients are obese, very young (with smaller airways) or old (with potential cervical spine changes), or have physical characteristics like short necks, facial hair, teeth and mouth problems or large tongues. Pregnancy can cause challenges too, especially late, as the growing baby displaces blood and tissue upward.
What you do when laryngoscopy/intubation proves resistant depends on your setting. In the hospital, you may have a highly trained anesthesia team available to assist.
鈥淭hey鈥檙e the experts in any hospital,鈥� said Shay, who works for North American Partners in Anesthesia at UPMC Community Osteopathic in Harrisburg, Pennsylvania. 鈥淢ost hospitals have at least one anesthesia provider, often 24/7 for respiratory or cardiac arrest responses or any airway emergencies or intubations. We have an amazing array of medications and an armamentarium of management equipment at our disposal that鈥檚 not available to EMS. And while we鈥檙e trained to function as sole practitioners, we can always summon assistance.鈥�
EMS, not so much. Often it鈥檚 just you and your partner out there on a figurative island. 鈥淵ou really need to learn how to be able to function on your own,鈥� Shay added. 鈥淭he field can be very unforgiving.鈥�
PRACTICE MAKES PROFICIENCY
In both environments, managing the airway starts with a plan: How do caregivers expect to control it? Will basic measures be sufficient, or are advanced measures required? What factors will affect the process? Are all needed tools at hand and all players on the same page? And, vitally, what鈥檚 plan B if plan A fails?
For EMS those stakes are high. Not only does it lack the backup of hospital colleagues in critical situations, but its patients are often less stable 鈥� significantly sick or injured. If they鈥檙e dire enough to need intubation, their survival may rely on getting it right.
It鈥檚 no big secret that doing that starts with practice.
鈥淚 encourage EMS providers to use manikin or simulation training on a regular basis to improve their skill, technique, performance and skill retention,鈥� said Shay. 鈥淚t鈥檚 imperative that they feel comfortable with performing all those skills, whether it鈥檚 BVM ventilation or endotracheal intubation or needle or surgical cricothyrotomy. They need to be well trained and understand their devices.鈥�
On scenes, take advantage of the resources you do have. Some services may have supervisors or second units available to assist in cases like difficult airways or advanced interventions, and BLS providers can be great assets as well in setting up, locating and handling equipment, and supporting and facilitating paramedic performance of the actual skills.
Shay suggests a mnemonic of 鈥渢hree Ps鈥� to help optimize first-pass success: preparation, positioning and performance.
Preparation 鈥� Seconds may count in airway management, but taking a few at the outset to evaluate your patient鈥檚 particulars will save you more later. Do a quick visual assessment of the airway: Is there a foreign-body obstruction? Blood, vomit or mucus? Have equipment prepared in advance to perform suction and clear the playing field. Have laryngoscopes and stylets and tubes ready at hand.
鈥淐onsider every airway difficult,鈥� Shay advised. 鈥淏uild plans and backup plans that focus on airway management, not just intubation. Our goal may be successful intubation, but if for some reason we don鈥檛 like what we see, we have to be ready to back out, mask ventilate and proceed with a secondary plan.鈥�
Positioning 鈥� Patient positioning is important but can be neglected. A blanket or pillow beneath the head achieves the correct 鈥渟niffing鈥� position with the ears above the clavicle. Also elevate the stretcher head at least 10鈥�15 degrees if possible 鈥� always intubate down, not up.
Performance 鈥� Use the best approach for best results: Work from the head, with the patient properly positioned and tools at hand. All providers should know the plan. Use well-practiced tools and techniques. 鈥淵ou want to be disciplined and controlled and focused 鈥� using what I like to call 鈥榓irway zen,鈥欌�� said Shay. 鈥淭he three Ps are integral to that.鈥�
Finally, EMS organizations have a responsibility here too. They must arm their providers with the right tools and technologies to help them achieve success.
Among those tools in 2024 is video laryngoscopy.
VIDEO LARYNGOSCOPY IMPROVES THE ODDS
The first video scopes made an immediate impact when they arrived a quarter century ago and have continued to advance since. There is little question across the recent scientific literature that they improve first-pass success.8鈥�12
鈥淭he days of just doing direct laryngoscopy are over,鈥� said Shay. 鈥淭here are video laryngoscopy devices out there now that really give EMS providers that edge that is constantly available to anesthesia providers.鈥�
Among those is the from . The company鈥檚 latest enhancements to the device help providers both experienced and novice achieve first-pass success faster and with fewer adverse events.
Featuring the Macintosh blade familiar to most providers and an ergonomic design to maximize user comfort, the McGRATH MAC provides line-of-sight video with improved optics, durability for the field and features to help monitor and preserve battery life. It supports clinician safety by allowing users to stand upright while intubating, reducing exposure to droplets and potential pathogens.
Shay saw an early version of the device at a nursing conference several years ago and liked it enough to approach Medtronic reps.
鈥淚 told them how much I loved the device, and if anyone needed it, it would be EMS 鈥� this is literally the perfect device for EMS,鈥� he recalled. 鈥淚t鈥檚 the closest thing to a traditional Macintosh direct laryngoscopy device, which is what every EMS and anesthesia provider originally trains on. And when we talk about best approaches and building technique, we always fall back on these original direct laryngoscopy techniques. The McGRATH MAC just feels natural in the hand of an experienced advanced airway management provider.鈥�
Priced at a point affordable for EMS, it鈥檚 now the main video laryngoscope used across 14 anesthesia sites operated by Shay鈥檚 employer.
鈥淎ll of our providers love it 鈥� it鈥檚 their go-to device,鈥� he added. 鈥淚 believe the thing sells itself.鈥�
For more information, visit .
REFERENCES
1. 鈥淓MS field intubation.鈥� David M. Gnugnoli, Abhishek Singh, Katherine Shafer. StatPearls [Internet]. 2023. www.ncbi.nlm.nih.gov/books/NBK538221/
2. 鈥淎ssociation between multiple intubation attempts and complications during emergency department airway management: A national emergency airway registry study.鈥� Michael D. April, Steven G. Schauer, Dhimitri A. Nikolla, et al. American Journal of Emergency Medicine. November 2024. www.sciencedirect.com/science/article/abs/pii/S0735675724004558
3. Association between repeated tracheal intubation attempts and adverse events in children in the emergency department.鈥� Hiraku Funakoshi, Yuri Kunitani, Tadahiro Goto, et al. Pediatric Emergency Care. February 2022. https://journals.lww.com/pec-online/abstract/2022/02000/association_between_repeated_tracheal_intubation.38.aspx
4. 鈥淎ssociation between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department.鈥� Edir S. Abid, Kelsey A. Miller, Michael C. Monuteaux, Joshua Nagler. Emergency Medicine Journal. 2022. https://emj.bmj.com/content/39/8/601.info
5. 鈥淭he importance of first pass success when performing orotracheal intubation in the emergency department.鈥� John C. Sakles, Stephen Chiu, Jarrod Mosier, et al. Academic Emergency Medicine. January 2013. www.ncbi.nlm.nih.gov/pmc/articles/PMC4530518/
6. 鈥淒ifficult airway assessment acronym.鈥� Anna Hernandez. Osmosis. June 2024. www.osmosis.org/answers/lemon-difficult-airway-assessment-acronym
7. 鈥淎 comprehensive review of difficult airway management strategies for patient safety.鈥� Hoon Jung. Anesthesia and Pain Medicine (Seoul). October 2023. www.ncbi.nlm.nih.gov/pmc/articles/PMC10635845/
8. 鈥淔irst-pass success of video laryngoscope compared with direct laryngoscope in intubations performed by residents in the emergency department.鈥� Akihiko Sugaya, Keiko Naito, Tadahiro Goto, et al. Cureus. October 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10665768/
9. 鈥淰ideo versus direct laryngoscopy for tracheal intubation of critically ill adults.鈥� Matthew E. Prekker, Brian E. Driver, Stacy A. Trent, et al. New England Journal of Medicine. June 2023. www.nejm.org/doi/full/10.1056/NEJMoa2301601
10. 鈥淭he impact of video laryngoscopy on the first-pass success rate of prehospital endotracheal intubation in the Netherlands: a retrospective observational study.鈥� Iscander Maissan, Esther van Lieshout, Timo de Jong, et al. European Journal of Trauma and Emergency Surgery. 2022. www.ncbi.nlm.nih.gov/pmc/articles/PMC9532291/
11. 鈥淰ideo laryngoscopy is associated with first-pass success in emergency department intubations for trauma patients: A propensity score matched analysis of the national emergency airway registry.鈥� Stacy A. Trent, Amy H. Kaji, Jestin N. Carlson, et al. Annals of Emergency Medicine. December 2021. www.annemergmed.com/article/S0196-0644(21)00696-X/abstract
12. 鈥淔irst-pass success intubations using video laryngoscopy versus direct laryngoscopy: A retrospective prehospital ambulance service study.鈥� Christopher M. Eberlein, Isidora S. Luther, Tom A. Carpenter, Luis D. Ramirez. Air Medical Journal. September鈥揙ctober 2019. https://pubmed.ncbi.nlm.nih.gov/31578974/
McGRATH MAC is a registered trademark of Medtronic.
