Airway management: The equipment and technique debate continues
If polled, it is reasonable to expect EMS personnel to rank advanced airway management as one of the most important prehospital interventions. Despite this attitude, numerous studies and case reports highlight the complications associated with advanced airway management, especially when inexperienced providers attempt to perform endotracheal intubation.[1-4] The American Heart Association acknowledges the lack of adequate evidence to recommend a specific advanced airway or to recommend the optimal timing for device insertion relative to other advanced procedures.
Airway error types
Researchers recently proposed a classification system for errors and complications created when attempting to use an advanced airway. This system includes technical errors, cognitive errors, and adverse anatomic effects.
Technical errors associated with advanced airway placement include airway misplacement, multiple failed attempts, prolonged attempts, and accidental dislodgement after correct placement. Technical errors may decrease ventilation effectiveness and increase the frequency and duration of interruptions in chest compressions during a resuscitation attempt.
Cognitive errors deal with the knowledge needed to perform a skill. EMS personnel must know the advantages and disadvantages of each of the different type of advanced airway devices, and well as the indication for use. Examples of cognitive errors in advanced airway management include patient assessment errors, failure to troubleshoot airway problems, and overcompensation for oxygenation and ventilation deficiencies. Overcompensation, in the form of hyperventilation is common in traumatic brain injury management and during resuscitation attempts following cardiac arrest that occurs both in the out-of-hospital and in-hospital settings.[15-17]
Post - ROSC arterial hyperoxia (a potential consequence of overcompensation) has also been shown to decrease survival to hospital discharge rates in adult patients who suffered cardiac arrest. Although arterial hyperoxia increases oxygen content of the blood, it also reduces regional perfusion through vasoconstriction. The net effect is decreased oxygen delivery to the organs and tissues.
The final category of errors and complications are those that produce anatomic abnormalities. For example, esophageal-tracheal tube insertion can result in tracheal injury, upper airway bleeding, tongue edema, or esophageal laceration or perforation. Overinflation of the laryngeal tube cuffs can cause swelling in the tongue significant enough to produce life-threatening airway obstruction. Complications related to the endotracheal intubation involving anatomic abnormalities include tongue perforation and tracheal laceration.[23,24]
Although trauma related to the use of endotracheal tube introducers is rare, most complications result from railroading, whereby the healthcare provider aggressively and forcefully pushes the endotracheal tube over the bougie even after meeting resistance. Use of the bougie has resulted in bronchial laceration, pharyngeal wall perforation, bleeding and blood clot formation in a mainstem bronchus, and tracheal perforation resulting in a complete intratracheal airway obstruction.
Using the most appropriate device
Despite the problems associated with advanced airway placement, EMS personnel can improve patient ventilation by inserting a supraglottic airway when compared to ventilation with a bag-mask even when the EMS provider has only limited training in advanced airway management. A recent investigation demonstrated that early insertion of a supraglottic airway significantly improved chest compression fraction when compared to bag-mask ventilation in patients who suffered an out-of-hospital cardiac arrest. This study did not measure survival outcomes however; other studies have demonstrated improvements in clinical outcomes with higher chest compression fractions.[32-34] The increase in chest compression fraction observed in the study is likely due to the change in compression/ventilation ratios that followed advanced airway insertion.
KISS principle applies
EMS providers should strive to keep things simple when deciding which airway device to use in a specific situation. Specifically for the paramedic practitioner, the airway toolbox is filled with a multitude of devices and procedures for establishing and maintaining airway patency. Paramedics should consider the following:
In general, the simpler the device or procedure, the greater the reliability and accuracy of its use. However, not all anatomic presentations or environmental conditions are conducive to simpler devices. EMS providers should be not only well versed in how to use every device and procedure available, but also to critically decide when to use the appropriate method and what other choices need to be used in case of failure.
Current and future studies
Researchers in France are currently investigating whether the use of an endotracheal tube improves 28-day survival with favorable neurological outcome following out-of-hospital cardiac arrest compared to use of bag-mask ventilation. The study is expected to conclude mid-year 2017.
Researchers in the United Kingdom are studying out-of-hospital cardiac arrest and comparing outcomes between 9,000 adult patients whose airways were managed with an endotracheal tube and those managed with a second generation supraglottic airway.  The primary outcome for the study, known as the UK AIRWAYS-2 study, is neurological outcome (as measured by the modified Rankin scale) at hospital discharge. Enrollment began early this year and is expected to conclude in late 2017.
Later this year, the Resuscitation Outcomes Consortium will begin enrolling patients into the Pragmatic Airway Resuscitation Trial (PART [ClinicalTrials.gov Identifier: NCT02419573]). For adult patients who develop cardiac arrest in the out-of-hospital environment, researchers will randomly allocate those patients to receive early advanced airway management with either an endotracheal tube or laryngeal tube. The primary outcome for the study will be 72-hour survival. By the time the study concludes in late 2020, the researchers expect to enroll 3,000 patients.
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35. ClinicalTrials.gov. (2015). Tracheal intubation vs. bag-valve-mask ventilation in patients with out-of-hospital cardiac arrest - CAAM STUDY [ClinicalTrials.gov Identifier: NCT02327026]. Retrieved from https://clinicaltrials.gov/ct2/show/NCT02327026?term=%22endotracheal+intubation%22+AND+%22cardiac+arrest%22&rank=1
36. BioMed Central. (2015). Airway management in out of hospital cardiac arrest patients [ISRCTN08256118]. Retrieved from http://www.isrctn.com/ISRCTN08256118?q=ISRCTN08256118&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search
37. ClinicalTrials.gov. (2015). Pragmatic airway resuscitation trial (PART). Retrieved from https://clinicaltrials.gov/ct2/show/NCT02419573?term=%22endotracheal+intubation%22+AND+%22cardiac+arrest%22&rank=2Kenny Navarro is an Assistant Professor in the Department of Emergency Medicine at the University of Texas Southwestern Medical School at Dallas. He also serves as the AHA Training Center Coordinator for Tarrant County College. Mr. Navarro serves as an Emergency Cardiovascular Care Content Consultant for the American Heart Association, served on two education subcommittees for NIH-funded research projects, as the Coordinator for the National EMS Education Standards Project, and as an expert writer for the National EMS Education Standards Implementation Team. Send correspondence concerning any articles in this section to Kenneth W. Navarro, The University of Texas Southwestern Medical School at Dallas, 5323 Harry Hines Blvd MC 8890, Dallas, Texas 75390-8890, or e-mail firstname.lastname@example.org.
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