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DOI: 10.4103/2229-5151.128014
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Advances in prehospital airway

management
PE Jacobs, A Grabinsky

ABSTRACT University of Washington / Harborview

Medical Center, Box 359724, 325 Ninth
Prehospital airway management is a key component of emergency responders and remains Avenue,Seattle, WA 98104
an important task of Emergency Medical Service (EMS) systems worldwide. The most
Address for correspondence:
advanced airway management techniques involving placement of oropharyngeal airways Paul E. Jacobs, DO,
such as the Laryngeal Mask Airway or endotracheal tube. Endotracheal tube placement University of Washington / Harborview
success is a common measure of out‑of‑hospital airway management quality. Regional Medical Center,
variation in regard to training, education, and procedural exposure may be the major Box 359724,
325 Ninth Avenue,Seattle, WA 98104.
contributor to the findings in success and patient outcome. In studies demonstrating poor E-mail: pejacobs@u.washington.edu
outcomes related to prehospital‑attempted endotracheal intubation (ETI), both training
and skill level of the provider are usually often low. Research supports a relationship
between the number of intubation experiences and ETI success. National standards for
certification of emergency medicine provider are in general too low to guarantee good
success rate in emergency airway management by paramedics and physicians. Some
paramedic training programs require more intense airway training above the national
standard and some EMS systems in Europe staff their system with anesthesia providers
instead. ETI remains the cornerstone of definitive prehospital airway management,
However, ETI is not without risk and outcomes data remains controversial. Many systems
may benefit from more input and guidance by the anesthesia department, which have
higher volumes of airway management procedures and extensive training and experience
not just with training of airway management but also with different airway management
techniques and adjuncts.
Key Words: Airway, anesthesiology, emergency, management, prehospital

INTRODUCTION airway management techniques involving placement

Prehospital airway management is a key component
of provider training and remains an important task of
Emergency Medical Service (EMS) systems worldwide.
The development of different prehospital airway
management techniques and equipment mirrors the
evolution of prehospital triage and emergency care.
Basic airway skills included in Basic Life Support (BLS)
training such as mouth‑to‑mouth‑ventilation,
mouth‑to‑nose‑ventilation or the use of simple face mask
devices have been taught to the general population for
decades.
of oropharyngeal airways such as the Laryngeal Mask
Airway (LMA), Combitube®, King LT® tube, and others
tend to be reserved for the more advanced level of
prehospital provider such as paramedics or physicians.
Similarly, endotracheal intubation (ETI), airway rescue
device placement, capnography, and cricothyroidotomy
remain the responsibility of either paramedics with
advanced airway training or physicians. In recent years,
advances in video‑assisted laryngoscopy (VAL) and the
refinement of oropharyngeal airways have shown the
potential to change or add to the traditional approach of
prehospital airway management.

More intermediate airway management techniques Many European countries operate with a physician
including bag‑mask ventilation (BMV) and placement of staffed EMS in which a physician is sent to life‑threatening
oral or nasal airway devices are utilized by Emergency emergencies. The majority of EMS systems in the United
Medical Technicians (EMTs). The most advanced States utilize nonphysician providers to manage the

International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014 57
 Jacobs and Grabinsky: Advances in prehospital airway management
prehospital airway. One important distinction between
the two EMS models is that EMT scope of practice within
the Franco–German model is significantly limited in
comparison to the American model of prehospital care.
Most procedures are only performed by physicians
unless there is an extraordinary circumstance where
no physician is readily available to treat the patient at
the scene. Within the European model, physician EMS
providers perform the required procedures. Both system
approaches rely on good education, high quality of
training, and recertification standards to ensure advanced
EMS providers are equipped with the skills necessary to
avoid life‑threatening complications from loss of airway
or respiratory problems.
Airway management by first responder (lay person)
Lay people, with or without BLS training, are often
the initial care providers at the scene of an emergency.
The often encountered reluctance of performing
mouth‑to‑mouth ventilation and the potential infection
risk have been viewed as barriers to the initial care
of nonbreathing patients. Observational studies have
shown that “panic” was stated by lay people as the
most common barrier to providing cardiopulmonary
resuscitation (CPR) to a patient. [1] A simpler model
employing “hands‑only” (chest compression without
conventional rescue breaths) was thought to potentially
decrease some barriers to first responder care.[2] In addition,
in an earlier study by Berg et al., assisted ventilation with
CPR in a swine animal model did not improve outcome
over hands‑only CPR.[3] Observational studies in adults
undergoing bystander CPR demonstrated similar survival
rates among individuals receiving hands‑only versus
conventional CPR with rescue breaths.[4‑6] Rationale for
these observations include delay in hypoxemia due
to adequate oxygenation at time of cardiovascular
collapse, passive gas exchange with chest compressions,
and agonal breathing patterns that may be present in a
patient undergoing CPR after cardiac arrest. However,
an acceptable length of time for hands‑only CPR has not
yet been established and most patients undergoing CPR
will eventually receive advanced airway management,
such as endotracheal tube (ETT) placement, by a medical
provider during the process.
The 2010 American Heart Association (AHA) guidelines
for CPR in adult patients now emphasize in the following
order circulation, airway, and breathing with a much
higher emphasis on chest compressions, rather than
ventilation. This is in contrast to the pediatric population
where conventional CPR with assisted ventilation
demonstrates improved outcomes versus hands‑only
CPR.[7]
Airway management by EMR/EMT
At the federal level, the National Highway Traffic Safety
Administration developed a minimum content and hour
58 International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
requirement for Emergency Medical Responder (EMR)/
EMT training (National Standard Curriculum) that all
states must meet.[8] Additionally, the National Highway
Traffic Safety Administration developed a National EMS
Scope of Practice Model which details the minimum
psychomotor skill set that each care provider is expected
to possess.[9]
However, current scope of practice is regulated at
the state level and can vary significantly between
states or even within varying regions of the same
state. The National Registry of Emergency Medical
Technicians (NREMT) developed certification tests
for each emergency responder level, and most states
currently use the NREMT guidelines as part of their
licensure procedure. A recertification process exists
including requirement for continuing education hours
and courses.
The EMR works alongside other EMSs and healthcare
professionals as part of the emergency care team.
Functioning as part of a tiered response system, EMRs
perform noninvasive interventions to reduce morbidity
and mortality associated with out‑of‑hospital medical
and trauma emergencies. The minimum psychomotor
skills provided by EMRs includes insertion of airway
adjuncts intended to go into the oropharynx, use of
bag‑valve‑mask, suctioning of upper airway, and use of
supplemental oxygen.
EMTs are subdivided into several classes including
EMT‑B (Basic), EMT‑I (Intermediate), and AEMT
(Advanced). The intermediate class of EMT is further
subdivided into the 1985 and 1999 grouping. As a rule,
minimum psychomotor skills and typical procedures in
respect to airway management include all those provided
by an EMR as well as insertion of airway adjuncts into
the nasopharynx and use of additional positive pressure
ventilation devices.
The Advanced EMT or AEMT is capable of providing
all interventions that an EMR, EMT‑B, and EMT‑I can
provide with additional minimum psychomotor airway
skills including insertion of airways that are not intended
to be placed into the trachea and tracheobronchial
suctioning of an already intubated patient.[9]
Airway management by paramedics/physicians
According to the NREMT guidelines posted on NREMT.
org, qualifications to become a paramedic includes age
18 years or older, current national or state certification at
the EMT‑B level or above, successful completion of a state
approved EMT‑paramedic/paramedic course or refresher
course that meets or exceeds the U.S. Department of
Transportation Paramedic National Standard Curriculum
within the past 2 years, and verification of current CPR
credentialing.
 Jacobs and Grabinsky: Advances in prehospital airway management
The U.S. Department of Transportation (DOT) pilot
testing of the curriculum demonstrated that an average
program with average students will achieve average
results after somewhere between 1000 and 1200 hours
of instruction.[8] Paramedic credentialing through the
NREMT requires successful passage of both a cognitive
and psychomotor examination. The cognitive examination
is a computer‑based examination encompassing
airway management, ventilation, oxygenation,
trauma, cardiology, medical, and EMS operations. The
examination content involves both adult and pediatric
patients. Psychomotor testing includes patient assessment
in a trauma situation, ventilatory management, cardiac
management skills, IV and medication skills, an oral case
examination portion, pediatric skills, and other skills
including spine immobilization. Airway and ventilatory
assessment includes use of bag‑valve‑mask, supraglottic
airway (SGA) placement, and ETI.
The physician‑staffed European EMS system (Franco–
German model) utilizes a multi‑tier system composed of
basic EMS providers with similar training to an EMT as
well as intermediate providers with skills and training
similar to that of an AEMT or paramedic. The last tier
is physician staffed ground vehicles or helicopters.
The physician is activated either by a dispatch center
or one of the first arriving care providers at the scene.
These physicians need to fulfill regional and national
requirements to be qualified to participate in the EMS
system. These requirements are not standardized but
usually include a minimum of 2 years of completed
residency training and procedural experience with
intubation, central line placement, and chest tube
placement.
Techniques for airway management prior to hospital
arrival
The decision about whether an airway intervention
is required is critical to patient care and survival.
Depending on the responder’s level of training, a quick
assessment and decision is made regarding what if any
intervention is required. Airway management is of course
limited by scope of practice, education of the practitioner,
and available resources.
Spontaneous breathing
Spontaneous breathing remains a viable option for airway
management when a provider is confronted with an
awake patient possessing a patent airway. Assistance
for spontaneous ventilation can be performed through
the placement of a nasal or oral airway. Oxygenation
can be improved with the supplementation of oxygen
via nasal cannula, simple face mask, or nonrebreather
face mask [Table 1]. Unfortunately, the maximally
achieved FiO2 is often over estimated by care providers
and hypoventilation resulting in hypercapnia cannot be
normalized with increase oxygen supply.
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
Table 1: Maximum oxygen FiO2 with different oxygen delivery
devices
Device Inhaled O2% Flow rate O2 (liter/minute)
Room air 21 ‑
Nasal cannula 24-44 @1-6
Simple face mask 35-60 @6-10
High flow mask 75 @10-12
Nonrebreather mask 90 @10215
with reservoir bag
Some EMS systems recently introduced continuous
positive airway pressure (CPAP) as an assist modality
for spontaneous breathing patients. To apply CPAP
the provider fixes a tight fitting mask to the patient
allowing CPAP during spontaneous ventilation. One
study examined the effectiveness of prehospital CPAP in
the management of acute pulmonary edema and found
decreased intubation rates and a mortality benefit in this
particular patient population.[10] However, this modality
requires the cooperation of the patient and can only be
performed in patients with intact mental status who
are able to follow instructions. Another disadvantage is
the amount of time required to apply and initiate this
form of assisted ventilation. As a temporizing measure,
CPAP and BiPAP may prove beneficial, however, it is
crucial for the prehospital care provider to recognize why
inadequate ventilation may be occurring and definitively
secure a patient’s airway if respiratory collapse appears
imminent.
Emergency conditions can greatly limit the safety of
allowing a patient to continue spontaneous ventilation.
This is especially true in the trauma situation where
impending airway or cardiovascular collapse may
necessitate early and aggressive airway management.
Mouth‑to‑Mouth ventilation
Mouth‑to‑mouth or mouth‑to‑nose ventilation is still
a recognized management technique for prehospital
airway management. However, this modality has fallen
out of favor recently with the increasing support of
“hands‑only” CPR. Proper face masks should be utilized
if they are available.
Bag‑mask‑ventilation
BMV remains a standard initial approach to airway
management in the prehospital and hospital settings. Proper
preoxygenation prior to intubation provides patients with
improved oxygenation and increases time to hypoxemia.
BMV can be applied as a sole practitioner or in conjunction
with a second care provider. BMV can also occur during
spontaneous respirations as a pressure support method
for patients with depressed tidal volumes and inadequate
ventilation. This is similar to the use of CPAP or BiPAP to
assist patients who are spontaneously breathing but are
not adequately oxygenating or ventilating.
59
 Jacobs and Grabinsky: Advances in prehospital airway management
Oropharyngeal and nasopharyngeal airways
Used as an adjunct device for spontaneous or assisted
ventilation, oropharyngeal and nasopharyngeal airways
are frequently utilized by prehospital care providers to
improve oxygenation and ventilation. These devices
are frequently used to temporize until a more definitive
airway is obtained, and there are several circumstances
that prohibit their placement (severe head or facial
injuries).
Supraglottic airway devices
Supraglottic airway (SGA) device placement requires
less training than ETI.[11] As a procedure, it is certainly
less invasive than ETI. For care providers not sufficiently
trained in ETI these devices can offer better ventilation
during transport than BMV alone. In addition, SGAs
can be used as a backup tool for failed intubation in
accordance with the difficult airway algorithm by the
American Society of Anesthesiology (ASA).[12]
Some of the more common SGAs include the LMA,
laryngeal tube, and Combitube. Initial evaluations of
SGA devices as an alternative to ETI for the prehospital
provider were promising.[13] Unfortunately, unexpected
complications such as aspiration, soft tissue injury,
airway injury, hypoxemia, hypercarbia, and vocal cord
injury have been associated with these devices.
Endotracheal intubation
The gold standard for definitive airway management in
the prehospital setting remains ETI. A cuffed tube in the
trachea allows for positive pressure ventilation, positive
end‑expiratory pressure (PEEP), positive pressure
recruitment maneuvers, and protection from aspiration.
Multiple studies support the model that proficient ETI
requires rigorous training and higher numbers of ETI
experience.[14]
Providers must know how to detect proper tube placement
using physical examination and capnography and also
be equipped to handle failed intubations. Proficiency
with the gum elastic bougie or intubating LMAs can
help providers rescue difficult airways. Additionally,
prehospital airway specialists must be capable of
performing a cricothyroidotomy when other methods of
ventilation are either unsafe or impossible.
Rapid sequence intubation versus no‑medication in‑
tubation
Pharmacologic muscle paralysis relaxes the pharyngeal
and facial musculature and results in improved intubation
conditions. Rapid sequence intubation (RSI) techniques
incorporate pharmacologic muscle relaxation and are
utilized by anesthesiologists and emergency medicine
physicians. However, one drawback to these techniques
is the elimination of a patient’s ability to breathe
spontaneously if the intubation fails. Yet many providers
60 International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
conversely argue that optimal intubating conditions
should be achieved prior to attempted intubation in the
prehospital setting. The reason for this is that prehospital
airway intervention is frequently time sensitive due to
trauma, cardiac arrest, hypoxemia, or aspiration risk.
Outcomes and discussion
While there is little debate regarding the importance
of airway management, continued debate exists over
prehospital ETI. Many existing publications to date
support the notion that prehospital ETI correlates with
higher incidence of mortality.[15]
One prospective study by Cobas et al. showed a 31%
incidence of failed prehospital intubation (PHI), but
found no difference in mortality between patients who
were properly intubated and those who were not.[16]
This study suggested the use of bag‑valve‑mask as an
adequate alternative method of airway management
for critically ill trauma patients. When compared with
BMV, one recent study demonstrated advanced airway
management to be independently associated with
decreased odds of neurologically favorable survival.[17]
Still other studies would suggest that ETI in the field
is a vital component to patient survival. Miraflor et al.
demonstrated that the timing of intubation of initially
stable, moderately injured trauma patients affects
mortality. Early intubation was associated with an
85% mortality risk reduction in this particular patient
population.[18]
An unrelated outcomes analysis from a major trauma
registry demonstrated an association between intubation
and mortality among individual trauma patients with
a Glasgow Coma Scale (GCS) of 8 or less. However,
the sub‑analysis suggested that sites with increased
intubation attempts had instead a decreased mortality
rate. The EMS system (Medic One) in King County, WA
utilizes prehospital ETI extensively and shows improved
survival rates when compared with systems participating
in this study with fewer PHIs.[19]
A clinical outcomes paper from Resuscitation combined
data from 16 U.S. states and examined out of hospital
airway management and outcomes. The data was pooled
from the 2008 National Emergency Medical Services
Information System (NEMSIS) Public Release Data
Set. With 4,383,768 EMS activations, 10,356 ETIs were
performed, 2246 alternate airways were placed, and 88
cricothyroidotomies were performed. Overall ETI success
rate was 77%. Regional variability demonstrated the
highest ETI failure rate to exist in the southern USA.[20]
A physician staffed EMS system in Germany demonstrated
a significantly higher number of patients being discharged
after suffering cardiac arrest (17.1%) than a paramedic
 Jacobs and Grabinsky: Advances in prehospital airway management
staffed system (3.9%).[21] Some attribute this difference in
outcome to the fact that physicians in the German EMS
system possess superior airway management skills.[22] In
contrast to that study, a study by Nichol et al. demonstrated
that Seattle, WA paramedic treated out‑of‑hospital cardiac
arrest (OHCA) patients survived to discharge 16.3% of
the time and therefore better than the other participating
systems.[23] However, it is important to note that there was
great regional variability in survival to discharge data
between the systems. The King County EMS system (Medic
One) does maintain a rigorous airway training program
with intubation success rates of over 98%.[24] These studies
support the notion that superior airway management has a
strong correlation with training efforts and ultimately with
patient outcome. In regard to performance and outcome,
these studies also suggest that systems with well trained
paramedics can compete in performance and outcome
with physician staffed EMS models.
While data surrounding out‑of‑hospital ETI and survival
outcome remains conflicting, what is clear is that the
current level of training of U.S. paramedics and European
EMS physicians is not sufficient to guarantee a universally
acceptable intubation success rate. In Europe, many
procedure requirements are decreased locally to ensure
recruitment of an adequate number of physicians. For
example, some German states require only a minimum of
25 intubations to qualify as an EMS physician provider.[25]
This is far less than the approximate 200 intubations
that Bernhard et al. demonstrated to be necessary to
increase intubation success from 82% to 92%. [26] At
present, U.S. paramedic trainees require just five ETI
attempts for the national paramedic certification. Poor
training and lack of experience may explain why many
paramedic or physician staffed systems demonstrate poor
patient outcomes, low success rates, or high numbers of
complications with ETI.
Some have suggested that SGA devices should replace
ETI in the prehospital setting. Sunde et al. performed a
retrospective analysis of 347 adult OHCA patients in
Norway. The success rate of laryngeal tube insertion
was 85.3% with a first pass success rate of 74.4%. Air
leakage (17.6%) and aspiration (12.7%) were reported
complications.[27] A cadaveric study by Scmidbauer et al.
demonstrated that inspiratory pressures of 40 and 60
mbar led to esophageal insufflation in all studied devices
(LMA‑Supreme TM, LMA‑Proseal TM, laryngeal tubes
LTS‑D and LTS II, Combitube®, and i‑gel®).[28] Insufflation
pressures during out‑of‑hospital ventilation are difficult
to monitor, and unintended gastric and esophageal
insufflation may lead to aspiration. Additionally, there
are case reports of Combitube ® use contributing to
aspiration, injury, and vocal cord damage. [29] A swine
cardiac arrest model demonstrated compression of the
internal and external carotid vessels with SGA device
placement (King LTS‑D®, LMA Flexible®, Combitube®).[30]
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
A secondary analysis of data obtained from a multicenter
study of patients suffering from OHCA showed that ETI
was associated with improved outcomes over SGA device
insertion. [31] However, confounding variables in this
analysis may impact the applicability of these findings.
Additionally, other studies have shown no difference in
neurologically favorable outcomes between patients treated
with SGA devices and ETI in OHCA.[32] While SGA devices
will continue to remain a key component of prehospital
airway management, at present they have not replaced ETI.
Special considerations
Trauma victims are an interesting subgroup of the
prehospital patient. These individuals are frequently
hypovolemic from the traumatic insult. For example,
bilateral femur fractures can result in blood loss of
three liters or more, and pelvic fractures can result
in life‑threatening hemorrhage within minutes of the
injury. Prehospital ETI in trauma patients has been
associated with hypotension and decreased survival.[15]
However, securing the airway of a patient in the face of
impending hemodynamic collapse is critical. Induction
agents and positive pressure ventilation may further
worsen hypotension that the trauma victim is already
experiencing from hemorrhage. Positive pressure
ventilation causes a reduction in venous return to the
heart and can contribute to cardiovascular collapse.
Volume replacement (preferably with blood and clotting
factors) should be performed in conjunction with positive
pressure ventilation.
Proficient and reliable pediatric airway management
skills are difficult to acquire and maintain. One study
from Pediatrics concluded that LMA placement led
to more rapid establishment of an airway with fewer
demonstrated complications.[33] Despite airway insertion
times not being statistically different, paramedics in a
simulated pediatric respiratory arrest scenario preferred
the King Laryngeal Tube airway over conventional ETI.[34]
Other studies have suggested that LMA use is safe and
effective when compared with BMV during neonatal
resuscitation. [35] This patient population will likely
continue to remain a challenge to prehospital providers
until better education and maintenance standards exist.
Time to hospital arrival must be taken into consideration
and long distance travel prior to hospitalization may
necessitate ETI for airway management. For example,
fluid shifts from bleeding and restorative IV therapy
during resuscitation can lead to respiratory failure
from pulmonary edema. In this situation it is wise to
preemptively secure a patient’s airway prior to transport.
Airway management protocols for use in combat situations
have not yet been defined.[36] A study of prehospital airway
management from Operation Iraqi Freedom demonstrated
an ETI success rate of 95.7%. [37] This is in contrast to
61
 Jacobs and Grabinsky: Advances in prehospital airway management
one recent study that suggested that airway and chest
lifesaving interventions were most frequently missed in
combat situations.[38] No matter what current outcomes
data may imply, it is reasonable to expect that improved
protocols and rigorous training standards should improve
prehospital airway management in combat situations.
Future developments
Video airway management devices will likely become
a component of prehospital airway management
education in the future. At present, several portable
laryngoscopes including the Glidescope ®, Pentax ®,
Storz® (DCI and CMAC), Airtraq®, and McGrath® are
utilized by anesthesiology and emergency medicine
physicians. VAL is often used as a primary intubation
technique for patients with a presumed difficult airway
or cervical spine injury. Additionally, these video devices
are frequently utilized as a rescue technique for failed
intubation. However, wide spread acceptance of VAL in
the prehospital setting has yet to gain universal support.
To date, several studies have compared VAL with
conventional direct laryngoscopy (DL). Aziz et al.
demonstrated an overall success rate for Glidescope®
intubation of 97% with a 94% success rate of Glidescope®
intubation after failed DL.[39] Studies have demonstrated
that VAL led to improved glottic visualization, however,
intubation times varied between different VAL devices
and were not globally superior to DL.[40] Additionally,
studies have demonstrated great variability in ETI success
rates between different types of VAL devices.[41] This
makes it impossible to extrapolate data from one study
and apply it to all VAL devices.
One review article highlighted increased first‑attempt
success and decreased time to intubation in studies of
nonexperts with the Glidescope ® compared with DL.
However, these authors suggested the need for further
investigation into this correlation.[42]
One paramedic study again supported the conclusion
that glottic visualization was improved with VAL. [43]
However, the same study found similar ETI success
rates between VAL and DL. Despite conflicting data, it is
reasonable to expect that VAL will become an important
technique for prehospital airway providers. Improved
access to these devices during provider training will
increase familiarity and comfort with VAL.
Additional future considerations include the
implementation of capnography in the prehospital
setting. This modality offers noninvasive confirmation
of ETT placement, provides a real‑time measure of a
patient’s ventilatory status, and can assist in advanced
airway placement.[44,45] Increasing use of capnography
within the field of emergency medicine will likely
translate to future use in the prehospital setting as well.
62 International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014
CONCLUSION
ETI success is a common measure of out‑of‑hospital
airway management quality. Some studies suggest that
prehospital ETI success ranges from 69% to 98.4%.[46‑51]
Regional variation in regard to training, education, and
procedural exposure may be the major contributor to
these findings. In studies demonstrating poor outcomes
related to prehospital‑attempted ETI, both training and
skill level of the provider are usually is often low.
Research supports a relationship between the number
of intubation experiences and ETI success.[26] National
standards for paramedics currently require a minimum
of five intubations for certification. The minimum
requirement for physicians participating German EMS
systems is anywhere from 25 to 50 intubations. The
ACGME mandates that 35 intubations are required
for emergency medicine residents during training.[52]
When compared with the greater than 1000 experiences
that anesthesiology residents are exposed to during
their training these minimum requirements appear
inadequate. One survey of paramedic training programs
reported that the median number of ETIs per student was
7 and suggested that 20-25 ETIs were required to achieve
an overall success rate of 90%.[53]
Some training programs, such as King County, WA offer
paramedic students early access to airway management
skills through hands‑on skill labs, lectures, and
involvement in the operating room setting. Paramedic
students learn the basics of airway management in a
controlled environment under the close supervision of
anesthesiologists, anesthesiology residents, and CRNAs.
Following this thorough introduction, senior level
paramedics assume the role of educators and further
instruct paramedic trainees on how to properly manage
the prehospital airway. More rigorous paramedic training
programs (such as King County, WA) report significantly
higher success rates with prehospital ETI.[24] In regard
to ETI, development of more rigorous and universally
accepted training standards would likely lead to
improved success rates and outcomes, in paramedic and
physician staffed systems.
ETI remains the cornerstone of definitive prehospital
airway management. However, ETI is not without risk
and outcomes data remains controversial. At present, ETI
has not been replaced by SGA devices in the prehospital
setting. However, these devices continue to gain favor
in certain patient populations. [33‑35] As technology
and provider experience improves, it is reasonable to
believe that VAL will likely become a widely accepted
prehospital airway modality. Additionally, capnography
will most likely become a component of prehospital
provider education and daily practice. Many systems
may benefit from more input and guidance by the
 Jacobs and Grabinsky: Advances in prehospital airway management
anesthesia department, which have higher volumes in
regard to airway management and extensive training and
experience not just with training of airway management
but also with different airway management techniques
and adjuncts.
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Cite this article as: Jacobs PE, Grabinsky A. Advances in prehospital
airway management. Int J Crit Illn Inj Sci 2014;4:57-64.
Source of Support: Nil, Conflict of Interest: No.

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