Prehospital Airway Management

Are your prehospital airway choices based on outdated tradition or true patient outcomes? In this episode of From Science to the Scene, host Chris Gage breaks down a ground-breaking evidence-based guideline that is reshaping how every Clinician approaches the airway. Discover why basic bag-valve-mask ventilation remains the core foundation of care and learn why supraglottic airways are often the smarter choice over endotracheal intubation. The episode also uncovers critical safety warnings regarding pediatric patients, emphasizing why lower procedural volume requires extreme caution. Most importantly, you will see how focusing on continuous waveform capnography and protecting patient blood pressure makes all the difference in successful resuscitation. Tune in now to elevate your practice and bring true science to your next shift.

Read the full evidence-based guideline study here: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2832116

Transcript

SPEAKER_00 0:15

Every shift, somewhere, an EMS crew is making an airway decision under pressure. And honestly, for decades, many of those calls lean more on tradition than evidence. Welcome back to the podcast. My name is Chris Gage, and today I'm walking through an evidence-based guideline for pre-hospital airway management, written by a panel of pre-hospital airway experts and published in PEC. Airway management is one of the core procedures in EMS, right? We teach it early, we practice it often, and honestly, it's treated as foundational. But underneath it sits a hard question. What's the best airway strategy for the patient in front of us? For decades, our options have always been back valve mass ventilation, superglotic airways, and endotracheal intubation. Each has advantages, each has risk, and each performs differently depending on the patient, the condition, even the clinician, right? And even the system you're in. So this guideline was built to move EMS past tradition and preference towards an evidence-based approach to airway decisions. So it started from the systematic review who was performed by the Agency for Healthcare Research and Quality. So they're called AHRQ. So a technical expert panel then graded that evidence using GRADE, a structured way to judge how certain the evidence is. The final product got 22 recommendations plus a set of good practice statements to help translate the evidence into daily EMS practice. So one thing to understand up front, most of these recommendations are conditional. It doesn't mean they're weak. It just means the evidence was very limited, low, or very low certainty. So the guideline isn't naming one universal correct airway for every patient. It's saying airway decisions should be based on the clinical condition, patient age, available resources, and the demonstrated competency of the EMS system. The first major area is out-of-hospital cardiac arrest. So when we think about for adults in cardiac arrest, BVM alone, a superglottic airway, or endotracheal inhibition may all be reasonable. But comparing superglottic airway to inhabition, there's a key distinction. And systems without demonstrated high inhibition proficiency favor the superglottic airway. And systems with proven proficiency with innovation, either is appropriate. And that distinction is critical. It's not about the device, it's about the system using it. A service with strong training, quality review, and consistently with high first pass success can reasonably approach the airway differently than one where innovation is rare or success isn't measured at all. For pediatric cardiac arrest patients, the panel is more cautious about inhabitants, favoring both BVM and superglottic airways over endotracheal inhabitants. That matters because pediatric airway management is rare, and honestly, it's technically hard. Children aren't just small adults. Anatomy, physiology, and procedural success vary by age, so the harms of a failed or repeated innubation attempts can outweigh the benefit when you ventilate effectively another way. So the second major area they looked at is trauma. For adult trauma, BVM, superglottic airway, and inhabition may all be used. That sounds neutral, but the point isn't that every choice is equal. It's just that the evidence doesn't clearly favor one universal approach. In trauma, the goal isn't to just get the tube in place, it's to optimize oxygenation and ventilation while avoiding harm. That's especially true in traumatic brain injuries where hypoxia, hypotension, and hypoventilation worsen outcomes. A technically sufficient and successful attempt that causes severe desaturation and hypotension is not really clinically successful. So for pediatric trauma patients, the evidence is even thinner. The guideline found too little to compare BVM with a superglottic airway, and it favors the superglottic airway over innovation. The message again is caution. The panel specifically warns this should not be read as broad endorsement of pediatric innovation. Any positive pressure ventilation in children requires focused training and ongoing competency. So the third major area they looked at was medical emergencies. For medical emergencies, unfortunately, the evidence is even more sparse. The panel found too little to compare BVM with either superglodic airway or innovation. Comparing superglodic airway to innovation, either may be used in adults and children, but the nuance matters. Agencies with documented high innovation success may use either, while those with without high documentation of success should probably lean more towards a superglottic airway. For the pediatric medical emergencies, the panel favors superglottic airways most over for any agency. While recognizing some high-volume specialty systems, they do have training and oversight to support innovation. So the fourth major area is the technical modifiers. For medication assisted management, the panel suggests rapid sequence innovation or induction over no medication and over sedation without paralysis, but only in well-resourced, high-functioning settings. It made no recommendation on sedation-only innovation because the evidence is just too uncertain. Here again, the system level man message matters. RSI isn't a drug sequence. It's a high-risk strategy that demands training, monitoring, clinical governance, and quality improvement. And continuous physiologic monitoring is mandatory during invasive airway management, right? Blood pressure, heart rate, oxygen saturation, and definitely waveform entitled capnography. On video versus direct laryngoscopy, the panel says either may be used, but the pre-hospital evidence was mixed. And device type, blade, geometry, training, and local experience all matter, right? So the point just isn't simple video is better, direct is enough. It's that agencies need to train and measure performance with the devices they actually use. Stepping back from the individual recommendations, I think there are several themes EMS leaders and clinicians should take from this guideline. The first theme is that BVM ventilation is foundational, but it is not easy. Because BVM is within every EMS clinician's scope. We treat it as like basic, right? But basic doesn't mean simple. Good BVM ventilation takes positioning, a seal, a patent airway, the right rate, volume, and often more than just one provider. In some cases, like in cardiac arrests with limited personnel, a superglatic airway may deliver more reliable ventilation while freeing the other team up for other resuscitation tasks. The second theme is that airway management should be physiologic first. The endpoint isn't just a device, it's oxygenation, ventilation, henodnamic stability, and avoiding preventable complications. That means pre-oxygenation, blood pressure support before attempts, first pass success, and avoiding peri-inhabation, hypoxia, and hypotension. This is where the dash 1A comes in. Definitive airway, sans hypoxia or hypotension on the first attempt. It's a far more patient-centered way to think about success. It's not enough to ask, did the tube go in? We have to ask, did we get the airway without making the patient worse? The third theme is waveform entitle capnography is non-negotiable for any invasive airway. So the guideline emphasizes that waveform capnography to confirm initial placement, monitor ongoing placement, and assess ventilation throughout care. Confirmation cannot be a one-time event. It is best to be continuous throughout the whole time. The fourth theme is that competency matters more than capability. Many systems technically allow innovation, but the real question is whether they can demonstrate high proficiency. So tracking first-time past success, overall success, complications, periinovation, hypoxia, and hypertension, number of attempts, right? Device switching, and the patient outcomes were possible, where possible. So first past success among paramedics varies widely in the literature, and there's no universal threshold for what counts as high. That puts the responsibility on agencies and medical directors to measure their own performance and decide whether their airway strategy fits their system. The fifth theme is that pediatric airway management deserves special caution. Across either cardiac arrest, trauma, and medical conditions, the guideline repeatedly raises concern about pediatric innovation. It's rare most of the time. Opportunities stay current to opportunities to stay current are very limited, and complications from failed attempts can be very serious. For many agencies, emphasizing BVM and supergalodic airways is safer and more realistic about maintaining broad pediatric innovation capability. Finally, the guideline is honest about the limitations of the evidence. Most recommendations rest on low or very low certainty of evidence. Many studies were observational and subject to bias, honestly. Some are older devices or standards of care, and key questions like delayed sequence innovation, ketamine own innovation, and differences between specific superglodic airway devices themselves, they were unanswered in this. So this isn't the final word on pre-hospital airway management. It's the best informed evidence guideline we have right now. And a call for better research, honestly, better data, and better measurement. For agencies, the practical message is this review your airway protocols, but also review your airway performance. Know your first pass success, your complication rates, how often your clinicians actually perform these skills, and whether your training and quality improvement can support the procedures that you authorize. For clinicians, choose the strategy that best supports oxygenation, ventilation, and perfusion for the patient in front of you. Don't let the procedure come more important than the physiology. Use waveform capnography, avoid hypoxia and hypotension, limit repeated attempts, and recognize when a simpler airway just is the best airway to use. In conclusion, this guideline gives EMS a structured way to think about the airway. It reinforces BVM as the foundation, supports superglodic airway in many settings, urges caution with innovation when proficiency isn't demonstrated, and measures success by patient-centered outcomes. The central message isn't that one device wins, it's that airway management must be deliberate, evidence informed, physiology focused, and matched to your system's capabilities. Well, thanks for joining in today. Whether you're hitting the books or hitting the streets, stay safe, stay curious, and keep bringing science to the scene. Thanks.