Airway management

Airway management by endotracheal intubation (ETI) was one of the first advanced clinical interventions that laid the foundation for sophisticated prehospital clinical care. In 1977, the skill was described as being performed by “rescue personnel.” Now, prehospital medicine has evolved from focus on the ability to perform psychomotor skills, and EMS providers have an array of cognitive abilities at their disposal. This creates the expectation that they will choose to perform psychomotor skills that have the greatest impact on patient outcome.  

The selection of one intervention over another, such as using a supra-glottic airway over an endotracheal tube, requires sound contextual, clinical reasoning. To achieve and maintain competencies, initial and ongoing education must include an understanding of case specific pathophysiology, clinical judgment, and the ability to make higher order decisions. A variety of education tools must be employed. They include: low fidelity simulations, high fidelity simulations, cadaver labs, operating room rotations, and clinical field experience. Quality improvement programs must be implemented, continually evaluated, and used to identify strengths and weaknesses based on patient outcomes. Although endotracheal intubation is only one type of airway management, adverse outcomes related to ETI are significant sources of morbidity, mortality, and malpractice exposure. Consequently, we’ll focus on ETI. 

Data 

There are multiple data elements to consider. Case demographics consider the age, sex, and comorbidities of the patient. Other factors include the indications for ETI and the context in which it was employed (i.e., trauma, medical, airway obstruction, cardiac arrest), the level of experience of the EMS clinician, and the availability of drugs and transportation means. The response intervals should be noted. 

Pre-intubation data is extensive: 

• Initial cardiac rhythm, heart rate, blood pressure, respiratory rate 
• Glasgow Coma Scale score 
• End-tidal CO2, oxygen saturation
• Oxygen delivery device/rate 
• Anticipated difficulty of intubation, Mallampati score 
  

Peri-intubation data begins with an update of items covered in pre-intubation, noting the lowest oxygen saturation, blood pressure and end-tidal CO2. A subjective description of the difficulty of the intubation is noted.  

Post-intubation and outcome data contains the complications and drugs used. The clinician should give a subjective description of success, which is compared to objective success as defined by the quality assurance program. It should be noted if ETI was achieved with first-pass success. Otherwise, the number of attempts should be identified. The airway devices used should be named. Patient survival is a key factor. 

It is important that each data element is well-defined. What is your definition of an ETI attempt? Is it the number of times a laryngoscope blade enters the mouth with the intention of ETI? What quality metrics might one consider? 

Quality metrics 

One goal of data acquisition is to obtain quantification that allows comparative evaluation. Sometimes this is simple counting. What is the number of ETI attempts? How many are successful and related to patient survival? How do the ETI outcomes compare to those for the use of supra-glottic airways? As an exercise, define the numerators and denominators based on your data elements that can be used for quality improvement. As an example, overall intubation success rate equals the number of successful intubation attempts divided by the total number of intubation attempts. 

Possible metrics include: 

• Patient intubation success 
• Frequency of airway deployment 
• Per-intubation hypoxemia 
• Peri-intubation hypotension 
• Complication rate (how are complications defined?) 
• Unrecognized esophageal intubation 
• Rate of unmanaged airway 

Summary 

Each EMS system must base its clinical activities on patient outcomes that are defined and identified by formal processes with strict medical control. This format may be applied to multiple current interventions. It may also be used as a template for the evaluation of new equipment or procedures. 

References 

• DeLeo BC. Endotracheal intubation by rescue squad personnel. Heart Lung. 1977;6(5):851-4. 
• Dorsett M, Panchal A, et alia, Prehospital Airway Management Training and Education: An NAEMSP Position Statement and Resource Document. Prehospital Emergency Care 2022;26:3:3-13 
• Vithalani V, Sondheim S, et alia, Quality Management of Prehospital Airway Programs: An NAEMSP Position Statement and Resource Document. Prehospital Emergency Care 2022;26:14-22.