A Story:
More than a few times, I have come into a class or a department behind an instructor where it was obvious that they were merely regurgitating the exact same thing they heard from an instructor. I know that because I heard the same nonsensical platitudes from instructors when I was coming up more than a decade ago and several times since. Repeating these platitudes to students does not make you look like an expert… except maybe to people who do not know any better. Below are some repackaged nonsense I have heard or experienced over the years.
Exhibit A
Teaching airway management and intubation as a single provider skill. Everything from the BVM and mask seal to the actual intubation are all tested and taught with a single provider. Unless they are testing, at which point the proctor lends a hand with bagging. In no way is this rooted in operational reality. Instructors who do not teach a team/multi-provider aspect to airway management are leaving their students at a disadvantage because they have no awareness of how it actually looks on scene. The students will have no awareness of how to manage the other assets that will be present on a scene and employ them to the greatest effect. They should be familiar with current practice: two hand mask seals, ELM, VL, etc. They should also be quite facile with how to integrate all of those tools into a system that effectively addresses the patient’s needs.
Exhibit B
Teaching students to hold their breath during an intubation attempt. This is an attempt to limit the time of the intubation attempt with the notion that whenever the student needs to breath again, this is also a good indication that it is time to abandon the attempt and re-oxygenate the patient. Preoxygenation has been a cornerstone of successful airway management in 2024 and for at least a decade before. The goal of which is to PROLONG THE SAFE APNEA PERIOD, also known as the time to desaturation. Of course, there are clinical situations where there is no hope of improving the safe apnea period, at which point a prudent provider would closely evaluate and reconsider their approach to that particular patient. Students must be taught the proper approach and importance of preoxygenation, not some nonsense about holding their breath (which has zero evidentiary support).
Exhibit C
Taking the largest blade in the kit, placing it in the patient’s mouth as far as it will go, and then backing out until “the cords drop into view.” Instructors, there are multiple sizes in the airway kit for a reason. That reason being is that a laryngoscope blade is not one size fits all. There are different sizes and blade shapes for different patient’s anatomy. “BuT Im A mAc tHreE guY” or “I cAn INtubaTe AnYonE WiTh a 4” if this is your mantra, pay attention… A blade that is too large carries a real risk of damaging the anatomy and/or forcing an inappropriate technique so that the wrong sized tool will work. Perhaps, unnecessarily exposing the patient to the real risk of damage to the airway tissues or other structures. A blade that is too small will fail to engage the tissues the way it is designed to and have similar results. Can we force either of these to work? Sure. But at what costs? Moreover, as an experienced clinician that
Progressive laryngoscopy is one better way to teach this. Especially now with the proliferation of video laryngoscopy. A student must be able to progressively identify their landmarks/waypoints along the way to the glottic opening. Tongue, uvula, glottis, arytenoids, cords. It is much harder to damage the airway structures this way, and it ensures that the operator knows where they are in relation to the patient’s airway anatomy. Knowing the anatomical waypoints to the vocal cords is a prerequisite for good airway management. Otherwise, how do they know they saw vocal cords? How do they know they are in the right place?
The Fix:
Instructors must be well read and prepared before they begin teaching something as dangerous (and litigious) as airway management skills. Intubation is a singular skill within the larger system of airway management. The focus should be on teaching approaches that reduce the likelihood of multiple attempts, desaturation, and peri/post intubation hypotension. At the bottom of this blog is a list of papers, some of which are foundational to the current way of prehospital airway management. Currency in clinical matters is not the only issue that needs to be addressed for instructors. We also have to be up on the new technologies and methodologies available to us to enhance our effectiveness as instructors. Experience is the obvious prerequisite for being an effective instructor, but being professionally educated and developed as an instructor is paramount to the success of the student AND the instructor. This keeps us from falling back on old habits or teaching the way we were taught simply because we do not know any other way.
As instructors, what we do and what we say matters. Everything matters. For some we are their entire frame of reference in some cases and we have to take that responsibility seriously.
My good buddy and I discuss this and other topics in this episode of the Alert Medic 1 Podcast:
Airway References:
Check these out to bolster your airway management resources:
Natt BS, Malo J, Hypes CD, Sakles JC, Mosier JM. Strategies to improve first attempt success at intubation in critically ill patients. Br J Anaesth. 2016 Sep;117 Suppl 1:i60-i68. doi: 10.1093/bja/aew061. Epub 2016 May 24. PMID: 27221259.
Jarvis JL, Gonzales J, Johns D, Sager L. Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia. Ann Emerg Med. 2018 Sep;72(3):272-279.e1. doi: 10.1016/j.annemergmed.2018.01.044. Epub 2018 Mar 9. PMID: 29530653.
Mosier JM, Sakles JC, Law JA, Brown CA 3rd, Brindley PG. Tracheal Intubation in the Critically Ill. Where We Came from and Where We Should Go. Am J Respir Crit Care Med. 2020 Apr 1;201(7):775-788. doi: 10.1164/rccm.201908-1636CI. PMID: 31895986.
Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012 Mar;59(3):165-75.e1. doi: 10.1016/j.annemergmed.2011.10.002. Epub 2011 Nov 3. PMID: 22050948.
Mosier JM. Physiologically difficult airway in critically ill patients: winning the race between haemoglobin desaturation and tracheal intubation. Br J Anaesth. 2020 Jul;125(1):e1-e4. doi: 10.1016/j.bja.2019.12.001. Epub 2019 Dec 24. PMID: 31882262.
Jaber S, Jung B, Corne P, Sebbane M, Muller L, Chanques G, Verzilli D, Jonquet O, Eledjam JJ, Lefrant JY. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med. 2010 Feb;36(2):248-55. doi: 10.1007/s00134-009-1717-8. Epub 2009 Nov 17. PMID: 19921148.
April MD, Arana A, Reynolds JC, Carlson JN, Davis WT, Schauer SG, Oliver JJ, Summers SM, Long B, Walls RM, Brown CA 3rd; NEAR Investigators. Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study. Resuscitation. 2021 May;162:403-411. doi: 10.1016/j.resuscitation.2021.02.039. Epub 2021 Mar 5. PMID: 33684505.
Khandelwal N, Khorsand S, Mitchell SH, Joffe AM. Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesth Analg. 2016 Apr;122(4):1101-7. doi: 10.1213/ANE.0000000000001184. PMID: 26866753.
Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the “sniff” and “ramped” positions. Obes Surg. 2004 Oct;14(9):1171-5. doi: 10.1381/0960892042386869. PMID: 15527629.
Mort TC. Preoxygenation in critically ill patients requiring emergency tracheal intubation. Crit Care Med. 2005 Nov;33(11):2672-5. doi: 10.1097/01.ccm.0000187131.67594.9e. PMID: 16276196.
Carney N, Totten AM, Cheney T, Jungbauer R, Neth MR, Weeks C, Davis-O’Reilly C, Fu R, Yu Y, Chou R, Daya M. Prehospital Airway Management: A Systematic Review. Prehosp Emerg Care. 2022 Sep-Oct;26(5):716-727. doi: 10.1080/10903127.2021.1940400. Epub 2021 Jul 20. PMID: 34115570.
Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Jones PM, Lemay F, Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Kovacs G; Canadian Airway Focus Group. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient. Can J Anaesth. 2021 Sep;68(9):1373-1404. doi: 10.1007/s12630-021-02007-0. Epub 2021 Jun 18. PMID: 34143394; PMCID: PMC8212585.
Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Kovacs G, Lemay F, Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Jones PM; Canadian Airway Focus Group. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway. Can J Anaesth. 2021 Sep;68(9):1405-1436. doi: 10.1007/s12630-021-02008-z. Epub 2021 Jun 8. PMID: 34105065; PMCID: PMC8186352.
Sakles, J. C., Chiu, S., Mosier, J., Walker, C., & Stolz, U. (2013). The importance of first pass success when performing orotracheal intubation in the emergency department. Academic Emergency Medicine: Official Journal Of The Society For Academic Emergency Medicine, 20(1), 71-78. doi:10.1111/acem.12055
Binks MJ et al. Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval: A Systematic Review and Meta-Analysis. Am J Emerg Med 2017; S0735 – 6757 (17): 30497. PMID: 28684195
Bick E, Barnes J, Roberts J. Can’t intubate can’t oxygenate: It takes more than a patent airway to oxygenate a patient. Eur J Anaesthesiol. 2020 Jun;37(6):503-504. doi: 10.1097/EJA.0000000000001143. PMID: 32379147.
