Throughout my career as an EMS provider, I always have been nervous about aggressively approaching airway management. I have had the training and somewhat the expertise, and now I have some street cred that really helps me out with my critical decision-making. Acquiring all of this has been no easy feat.
During my tenure as a paramedic, I have had numerous discussions with fellow EMS providers about how many intubations that they have compared with most. I might not have as many intubations as they have, but how important is the number of intubations anyway? For some, it’s about competency; for others, it fluffs their ego.
All that matters in regard to intubations is what is best for overall patient care.
Considering noninvasive
So, let’s get into this airway management mumbo jumbo. Starting at the basics, we have room air, nasal cannulas, non-rebreathers, Venturi-type non-rebreathers, nasopharyngeal airways (NPAs), oropharyngeal airways (OPAs), laryngeal mask airways (LMAs), etc. Appropriate treatment and management for any type of airway compromise, whether it be respiratory, traumatic or any other medical condition, should be approached conservatively but tailored for maintaining or improving respiratory protection and function. What do I mean by this? Do what’s most appropriate for your patient. If a patient is having severe respiratory distress, you can go straight to a non-rebreather or assist ventilations. Once you gain control of the overall illness, you can tailor back the intensity of your treatments, as long as your patient continues to maintain or improve.
I am a huge fan of utilizing noninvasive measures for respiratory distress, such as continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). When used appropriately at the right pressure settings, noninvasive treatments can be substantially lifesaving. This is where continued education and clinical experience assists in overall management
All that said, when it comes to taking someone’s airway, where do you draw a line? When do you pull the trigger on chemically paralyzing someone and ramming a plastic tube down that individual’s throat? The answer isn’t a simple one, and clinically it’s difficult to attach a specific oxygen saturation (SpO2) level, Glasgow Coma Scale (GCS) number or a respiratory severity classification while working on scene or in an ambulance. You might have heard “GCS below 8, intubate.” This is a good thought, but it isn’t absolute, and it doesn’t prompt the decision for me. Critical-thinking skills are required to decide whether a person no longer can support his/her own airway. These skills come with time.
Risks & danger
Intubation sometimes is known as a “monkey skill.” In other words, anyone can do it. Although, in essence, this is true, there are numerous reasons why it’s much more than that. Physiologically, many things go on.
If you have a patient who is in respiratory failure/extremis and you take away that person’s drive to breathe, you also take away the body’s drive to live, which is known as peri-intubation cardiac arrest (PICA). The body goes into an extremely relaxed state (Note: Although this isn’t a medical phrase, it does help to describe what the body does). When the patient is sedated, there is either a decreased drive or absence of drive to maintain or live. Pretreatment with pressors can assist with this not happening, but it isn’t completely helpful every time.
Intubation doesn’t come without risks. Even if you have 5,000 intubations under your belt, every intubation has a 15 percent chance of complication. Even the easiest intubations—with the best Mallampati score, in the perfect sniffing position, with equipment set up—still have their risks. Use caution before you to take someone’s drive to breathe away, because there is a possibility that it could be that person’s last time.
What the patient needs
Discussions on this subject can go on for hours. My bottom line here is to make sure you do what’s best for the patient—not for ease of patient handling by making rendering unconscious, not because “the hospital will do it anyway,” not to pack your stats.
Intubation is an invasive maneuver that could have life-altering, if not life-ending, effects. Providing the appropriate treatment for what a patient needs to not just make it to the hospital but make the return trip home is a very delicate balancing act.
Brandon Heggie
Brandon Heggie is a lieutenant firefighter/paramedic who has worked in fire and EMS for more than a decade. He served as a tactical medic on a SWAT team and is involved in high-angle rope rescue. Heggie provides in-depth knowledge in aggressive, simplistic medical assessment and care. He obtained an associate degree in emergency medicine and health services. As an instructor, Heggie provides a high-energy educational approach to maximize the learning experience and taught at Firehouse World and Firehouse Expo.
