EMS Field Intubation

Excerpt

Field intubation is the placement of an advanced airway or endotracheal tube (ET) by emergency medical services (EMS) personnel outside the hospital setting. There are many techniques available to control a patient’s airway or provide rescue ventilation and oxygenation to a patient. ET intubation (ETI), nasotracheal intubation, supraglottic airway devices, continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BPAP) machines are all viable options in the right clinical situations. ETI has long been the standard for airway control in the prehospital setting and is the focus of this article. While ET placement has a long history of use in the prehospital setting, its use is not without controversy. When compared to in-hospital intubation, higher failure and complication rates have brought the practice of field intubation into question. Nevertheless, there are times when airway control will be paramount, and the ability to intubate a patient who has no airway control is a critical skill needed for prehospital providers in the field. This procedure requires a clear understanding of the proper technique and indications for its use. Local protocols and medical direction should guide prehospital providers regarding their use.

The decision to intubate a patient should carefully be planned. The procedure can be technically challenging and lead to additional problems even in the best of circumstances. Provider competency and comfort with the procedure may also dictate whether a patient should be intubated. If a provider is unfamiliar or uncomfortable with performing field intubation, alternatives should be used if possible. Supraglottic airways and alternatives to intubation, such as continuing to provide ventilatory support via a bag-valve-mask (BVM) with airway adjuncts or CPAP and BPAP machines, might be better and safer alternatives in certain situations. The use of supraglottic airways, airway adjuncts, and CPAP/BPAP are discussed in separate articles and are not addressed here. There will be minor variances in technique and equipment used in-field intubation depending on provider competency and local protocols, but the main concepts should apply across all EMS jurisdictions. Field intubation should be used in patients that have lost control or have an impending loss of their airway, or patients that require increased ventilatory support that cannot be maintained through BVM ventilation and the use of airway adjuncts. Training and practice, appropriate patient evaluation and selection, and preparation in advance of difficult airway situations are all critical to the success of field intubation.

Despite a long history of prehospital airway management, there is conflicting evidence to show morbidity or mortality benefit when using prehospital intubation. Much of the published research has focused on the success rates and complication rates of the procedure. While it is crucial to continue to track prehospital personnel performing field intubation, future studies should also strive to identify emerging techniques, technology, and training methods to improve outcomes.