Emergency Airway Management: The Turf War Is Over

The head of the bed during an airway emergency is no longer solely the domain of anesthesia providers. Emergency airway management, including endotracheal intubation, is now performed by multiple providers inside and outside of the hospital.¹ Respiratory therapists (RTs) are among the personnel routinely performing safe and effective endotracheal intubation.²

In this issue of the Journal, Miller and colleagues³ describe a study that adds to the body of knowledge supporting RTs performing intubation.^4-7 The authors examined RT intubation outcomes in 2 facilities. The data indicated a 98% success rate with videolaryngoscopy used in 65% of initial attempts. Despite the study’s limitations, including the possible overestimation of success and underestimation of complications, the work supports the literature demonstrating the safety and efficacy of RTs performing endotracheal intubation.

Not all hospitals possess the same number and availability of airway experts. Large tertiary care centers have 24-h coverage by a team of anesthesia providers. Some of those are anesthesia trainees who need the out-of-operating-room airway experience. As the size of facilities decreases, the number and availability of airway experts often diminish, and RTs may be the experts called upon to manage airway emergencies 24/7. RTs are valuable members of the airway management team regardless of the setting.

The authors of an editorial published in Respiratory Care nearly 3 decades ago commented on a study describing a successful RT-provided intubation service.⁸ The authors indicated the need to provide quality care, what education was needed, the implications of technology, and that the turf war continued to be an issue.

Some of these issues are settled. The turf war is over.¹ The need to provide quality care and to continuously measure that quality remain. Facilities should regularly assess the success and complications of emergency airway management. The present study provides an example on how this can be accomplished. Changes in practice continue to make education and mastery of technology important issues.

An airway expert is more than the provider inserting an artificial airway device. The expert must have knowledge that includes anatomy, physiology, pharmacology, and pathophysiology. Possessing the ability to think quickly and critically is paramount to safely care for patients in potential respiratory compromise or failure. Decisions that must be made during an airway emergency include does the patient need an advanced airway such as an endotracheal tube (ETT), what is the urgency of the situation, are there other pharmacologic or non-pharmacologic modalities that have not been attempted, and (importantly) will the intubation be difficult?

The need for immediate control of the airway in cardiopulmonary arrest is clear and does not require pharmacologic adjuncts such as local anesthetics, opioids, sedatives, and neuromuscular-blocking agents for intubation. What about the patient who is currently adequately oxygenating and ventilating but is becoming fatigued and in impending respiratory failure? These patients are best managed using pharmacologic adjuncts to facilitate intubation. A plan must be in place to identify these patients and promptly notify a provider who is able to administer these medications if the RT is unable to do so. In this situation, the RT could perform the intubation following administration of medications by a physician or advanced practice provider. That physician or advanced practice provider could perform the intubation if they are more experienced than the RT in airway management. The proposed advanced practice RT (APRT) scope of practice describes the APRT being prepared to administer these medications.⁹ Preparation of sufficient numbers of APRTs is likely years away as currently < 50% of RTs possess a baccalaureate degree.¹⁰ Monitoring the quality of care by all providers continues to be important.

The scenario described above is more complicated when the patient is suspected of being difficult to intubate. There may be time to summon other airway experts. Successful management may be optimized using a team approach with team supporting the most experienced expert.

Didactic education and hands-on simulation are important teaching tools, but providers must gain experience with patients in real-world situations. Simulated experiences allow for teaching and attainment of proper intubation techniques but can be less than realistic because of the design of the mannequin or airway trainer.¹¹ The number of intubations the provider should perform during initial and sustainment training remains unsettled.

Students in nurse anesthesia programs must perform 250 successful intubations during their clinical residency.¹² There is no minimum number of intubations required by physician anesthesiology residents as the assumption is the resident will obtain a number of intubations that will far exceed the number needed to demonstrate proficiency.¹³ A review suggested that depending on how success is defined (failure rate of 10% or 20%) the number of intubations needed to demonstrate proficiency is between 22–75 attempts. There may be continued improvement of technique and increased success after 100 intubation attempts.¹³ Clinical resources (surgical cases requiring endotracheal intubation) may be difficult to obtain due to the number of trainees seeking experience and the increased use of supraglottic airways. Facilities should recognize there may not be sufficient clinical resources and should prioritize the trainees most needing airway management experience.

No discussion of airway management can ignore capnography. Capnography helps assure the provider in an often confusing and heated situation that the airway device is properly placed. The other advances in technology impacting airway management are the supraglottic airway and the videolaryngoscope (VL). An airway expert is no longer the person with a conventional laryngoscope in their coat pocket.

Alternatives to a failed intubation were limited in the past. Bag-valve-mask devices such as the Shiley Esophageal Endotracheal Airway, Double Lumen (Medtronic, Minneapolis, Minnesota); and the various invasive airway procedures such as the cricothyrotomy were alternatives when unable to successfully place an ETT. As described in the American Society of Anesthesiologists Difficult Airway Algorithm, the supraglottic airway is an alternative.¹⁴ The wave of supraglottic airways started in 1980s with the introduction of the laryngeal mask airway.¹⁵ There is now a wide variety of supraglottic airways. These devices provide a method of ventilating and delivering oxygen until a definitive airway can be established. An advantage of the supraglottic airway is its ease of use compared to endotracheal intubation. There are disadvantages, including perhaps a decreased efficacy at preventing aspiration. Very importantly, their use may help prevent multiple unsuccessful intubation attempts. Another advantage is the ability to place an ETT through the supraglottic airway into the trachea. With the plethora of supraglottic airways available, airway experts should agree on one or 2 types of supraglottic airways used in emergencies and train using these devices.

Finally, the VL has revolutionized the approach to endotracheal intubation. Conventional laryngoscopy results in the alignment of numerous axes for the provider to view the glottic opening. This is not necessary when using the VL. The device allows the laryngoscopist to see around corners. Many versions of VLs are available. Overall, VLs may improve glottic views and decrease the rate of failed intubations.¹⁶ Evidence also suggests that novice providers are successful with fewer experiences with the VL compared to conventional laryngoscopy.¹⁷ As a result of provider positioning and improved view of the glottic opening, the VL may also better protect the operator from infectious diseases such as COVID-19.¹⁸ Providers must consider the drawbacks of the VL including the cost, potential bulkiness, and complexity of the device compared to a conventional laryngoscope. The airway expert must be skilled in conventional laryngoscopy as these devices can become nonfunctional.

In many situations, the RT may be the only provider present in a facility to respond to airway emergencies. Regardless of the provider identified in a facility to respond to airway emergencies, RTs are valuable members of the airway management team.

Management of the emergency airway involves more than endotracheal intubation, and all providers must be educated on all of the facets of care of these patients. Determining the number of procedures needed for initial and sustainment training must be monitored. Airway experts must also continue to maintain currency with guidelines, techniques, and devices.

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