When techniques that paramedics could improve upon are discussed, often, the topic of advanced airway comes up. We have statistically low success rates in achieving an advanced airway with an endotracheal (ET) tube, and although there are other techniques that we can utilize (e.g., the i-gel), there are times when an advanced airway is critical in managing a patient’s airway. One example of such a circumstance is when a patient suffered an inhalation burn, and the threat of the airway closing from edema is high.
How do we improve our success rates in achieving an advanced airway with an ET tube in the field? One technique that’s beginning to show promise is utilization of the i-gel as a “guide” for the ET tube.
i-gel as guide
The belief behind this technique is that the i-gel’s shape and size make for a perfect tool to help to get the ET tube into place successfully. Nitin Choudhary and his co-authors wrote in “I-Gel as an intubation conduit: Comparison of three different types of endotracheal tubes” that their research showed that the ET tube had the highest first-attempt success rate for endotracheal intubation via i-gel compared with use of the intubating LMA supraglottic device and the flexible ET tube.
To accomplish this task, the i-gel is placed into the patient’s airway after preoxygenation. Once the i-gel is placed, the ET tube is inserted, with the i-gel acting as a channel for moving the ET tube into place.
When utilizing this skill, it’s imperative that one selects the correct i-gel size, because selecting the wrong size would impede the ET tube from being placed correctly and, therefore, prevent the patient from gaining any benefits of this technique.
The bougie
Another promising method for raising ET tube success rates is utilization of the bougie. The bougie is a flexible tip guide that doesn’t require the EMS provider to fully visualize the vocal cords during advancement.
To utilize this tool, introduce the bougie with the curved tip anteriorly and visualize the tip passing the vocal cords. If the latter isn’t possible, visualize the tip passing above the arytenoids. Once inserted, gently advance the bougie until you meet resistance; feel for the tracheal rings. From there, another crew member helps to advance the ET tube over the top of the bougie and guide it down into the trachea.
It’s important to acknowledge the issues that might arise from using the tool to assist with an advanced airway placement. Two problems one should keep in mind are the potential for airway trauma, including tracheal or bronchial perforation if placed incorrectly, and difficulty controlling the bougie because of its flexibility, particularly for novice users. The bougie should be used primarily as a rescue tool in difficult airway situations and not for routine intubation.
Video laryngoscopy
Utilizing video laryngoscopy also can help EMS providers successfully pass an ET tube. Although this option is more expensive to use than the other techniques, it provides a perfect view of the vocal cords along with a channel to help to guide the ET tube into place. One possible negative of using a video laryngoscope is that, occasionally, condensation can obstruct one’s view.
Much training
No matter which method that one chooses, the only surefire way to provide quality patient care is through practice.
Repetition is key when advancing any type of airway, so get your hands on a manikin that allows you that chance of multiple and regular training.
Go over your EMS bags thoroughly every chance that you get. Run through scenarios and where the tools are that you need to care for that patient.
The more that you practice with these methods, the better your outcomes, and the better the service that you can provide.
Megan Funk
Megan Funk entered into the fire service in 2013 and has spent the past eight years of her career with the St. Charles, IL, Fire Department as a firefighter/paramedic. She is involved with the department’s hands-on EMS training and health and wellness committee. Previously, Funk served with the Elk Grove Township, IL, Fire Department. She holds a master’s degree of biomedical science from the University of St Joseph.
