In the field and on the streets, most of our information around best practices in airway management were initially derived from the operating rooms and anesthesia. The information gathered at times can be relevant and therefore, we should consider adding it to our repertoire. Sometimes, other pieces of information trickles down from the OR, but doesn't necessarily correlate well in our EMS environment. Like everything else in life, we've got to take the good with the bad. The two worlds are vastly different, one is controlled and well-lit with perfect humidity, the other can be quite chaotic and unpredictable.
Q: Have you ever completed a retrospective evaluation of a missed endotracheal intubation? What could have been done better? What would you change if a similar scenario presented itself again? We learn arguably more from our failures, than we do from our successes. So -- why do we fail? According to the Southwest Journal of Pulmonary & Critical Care the phenotypes of intubation-related complications boil down to THREE things:
1. Incomplete Preparation -- this is always avoidable!!
2. Difficult Laryngoscopy - think mask seals, airway trauma - this can happen even despite adequate preparation.
3. Difficult Physiology - true difficult airway d/t underlying disease processes where safe apneic periods are altered/reduced.
As you can see in our earliest attempts - inadequate preparation can get us into trouble. Early trouble leads to more attempts and more attempts increases the incidence and likelihood of complications. This short blog post will focus on one relatively simple thing we can do before the laryngoscope ever enters the hypopharynx. These steps will position us for success...pun intended. Odds are we are intubating fewer patients today because of pharmacological advances and non-invasive airway devices like CPAP. Since these airway maneuvers come with some inherent risk and are occurring with lower frequency -- it simply reinforces why we should prepare even more.
Prior to your attempt, especially if they are apneic, consider apneic oxygenation (another topic for later) In all cases where an advanced airway will be deployed in a controlled or uncontrolled setting consider AIRWAY RAMPING - elevate the head of the stretcher and pull their shoulders up enough to where their occiput may come off the mattress. If they are on the floor, grab some sheets or something equivalent and place them under their shoulders and even parts of their neck depending on their body habitus. The goal here like the image above is to horizontally align their ear with their sternal notch. Doing this will:
+ Give you another distinct advantage - a leg up so to speak
+ Improve your view of the glottic opening for laryngoscopy (video preferred over direct)
+ Improve ventilation
+ Reduce the likelihood of aspiration
+ Better align their laryngeal and pharyngeal axis
+ Make you look like a star when you arrive to the ED
This same ear-to-sternal notch (sniffing) principle can and should be applied to pediatric patients as well. Improvised shoulder rolls work really well. Just be sure to not overextend the neck, as doing so will be counterproductive and hinder your view of the cords.
+ Every intubation is a big deal
+ Assume all intubations will be difficult
+ Have "pillowing" material available
+ Bariatric patients will require much more elevation - be prepared for that
Wishing you much success in your next intubation attempt!!
April 3, 2023
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC.