Three Cardinal Sins in Airway Management

-If your patient can't breathe, nothing else matters.1

When a lawyer calls me to review records in an EMS case, there's a high probability that it involves airway mismanagement.

Though there are no national statistics available, the majority of EMS lawsuits I have dealt with have been based in airway mistakes. In this article, I've identified three cardinal sins in airway management that will result in losing your patient and a visit to the local courthouse as defendant in a lawsuit.

Cardinal Sin No. 1: Failure to Ventilate

The thing that kills is not failure to intubate-it's failure to ventilate.

In one sense, basic rescuers have the best of all possible worlds. They have only oral and nasal airways, the BVM and possibly the dual lumen airway to work with. If you know how to use those devices, you can ventilate most patients.

But isn't endotracheal intubation the gold standard of airway management? Not if you can't intubate. Relying solely upon a higher and more complex method of airway management can give false security and lead to failure of airway control unless the practitioner falls back on basic skills.

"Evidence presented for the development of the American Heart Association's Emergency Cardiac Care Guidelines 2000 documented serious complications associated with attempted tracheal intubations by inadequately trained, inexperienced, or poorly supervised providers. Tracheal intubation may be no more effective than bag-mask ventilation and may even be harmful."2

Recently, I spoke to a paramedic friend about airway management, and I asked her what backup airway devices her service carries. "None," she said. When I recovered from my initial shock, I asked why. "Because our medical director says we ought to go to surgery and practice intubation until we know how to do it," she answered.

A fine and noble goal to be sure. Trouble is, sometime in your career you'll encounter a patient whom you cannot intubate. Even emergency department physicians and anesthesiologists have failures.

I have watched people attempt intubation until their patient turned purple, yet they never backed off or asked that the patient be ventilated. When ego gets in the way, patients die.

So, before embarking on an airway mission, ask yourself whether or not you can ventilate any patient you have to take care of. A surprising percentage of people I see taking advanced airway courses cannot, for several reasons.

They can't make a seal around the patient's mouth and nose with the BVM and fail to realize they are not getting adequate tidal volume into the patient.

They don't realize that people's faces have infinitely variable shapes and they must constantly reassess BVM position, hand position, patient's head and neck position, chest rise and fall and oxygen saturation, and that they should ask another rescuer to listen for breath sounds.

They forget that the best way to ventilate with the BVM is with three rescuers: one to hold the mask in place and keep the jaw extended, one to squeeze the bag and a third to apply Sellick's maneuver.

Cardinal Sin No. 2: Failure to Recognize a Failed Esophageal Intubation and Correct It

Most airway-related lawsuits I have been involved with focused on incorrect and unrecognized tube placement. Failure to recognize an esophageal intubation is an unforgivable sin; placing an endotracheal tube in the esophagus is not. If you do that, detect it, correct it and keep your patient ventilated, fine. Remember, it is ventilation, not intubation, that counts.

Misplaced endotracheal tubes happen in many ways. The difficult intubation is probably the No. 1 cause. Usually, the tube was never in the trachea to begin with. When you can't see the cords, it's tempting to put a little more bend on the end of the tube and poke it in, hoping it will go in the right place. Then, you fool yourself into thinking you're hearing breath sounds when you're not. After you're in the ambulance, it's virtually impossible to hear breath sounds.

So what do you rely on? Well, chest rise, if your patient's chest is not covered in six inches of fat; the end-tidal CO2 detector, and, if you're lucky enough to have it, capnography. There is also a simple tool everyone should carry: the inflatable bulb syringe. Devices like that are so cheap and easy to use that failure to use them puts you into a disadvantageous position if you have to defend yourself. The bulb syringe can be used to recheck tube placement and provide great evidence it's in the right place.

Regardless of what methods you use to verify tube placement, you must do it and document it. Time flies when you're working a code, and it's easy to get focused on something other than tube-placement verification. But remember, if you have a misplaced ET tube, defibrillation and all the drugs in the world will not save your patient.

Properly placed tubes can later become displaced. I have argued with folks who tell me that a properly inflated cuffed tube will not become misplaced. That assumes the cuff is, in fact, properly inflated, the tube is sized correctly for the patient and there are no leaks in the cuff. It also assumes the operator remembers to disconnect the syringe from the inflation tube immediately. If not, air will leave the cuff and re-enter the syringe.

Cadaver studies have shown that properly placed endotracheal tubes move up and down with flexion or extension of the neck.3 That's why placing a cervical immobilization collar on the patient after intubation is now recommended in the American Heart Association's Emergency Cardiac Care guidelines.4

In prehospital care, a patient may be moved many times. Consider this: The patient is intubated on the floor, then rolled onto a long board and lifted to a stretcher. The stretcher is rolled through several rooms, perhaps down stairs, across a lawn or street, and put into the ambulance. There are all sorts of bumps and turns along the way.

In the ambulance, the medic performing ventilations may have other duties, so the BVM is laid down, pulling traction on the tube. If drugs are injected down the tube, it's another opportunity for displacement.

When the ambulance turns corners, stops, starts and swerves, the patient moves. When the stretcher is taken out of the ambulance, moved to the resuscitation area of the ED and the patient is transferred from gurney to table, movement occurs. Tubes can become misplaced during any of these maneuvers, so continual tube-placement verification must be done and recorded. Remember, if you do not document tube-placement verification, you'll have no hard evidence that you did it.

Inability to see the cords is a major problem. We all know the "pucker factor" of arriving at a code involving an obese, no-neck patient. How many of us are prepared to deal with multiple attempts, each of which becomes more frustrating and accomplishes nothing except further compromised ventilation? Do you have a practiced and executable plan for dealing with that patient?

Cardinal Sin No. 3: Being Unprepared for the Difficult Airway

Some people are unclear on the concept of standard of care for airway management. Standard of care is a legal concept meaning that which a reasonable and prudent practitioner with the same level of education, training and experience would do in the same or similar circumstances. The definition seems simple enough. Application is more difficult.

In prehospital emergency care, it's a given that we will have to manage the airways of many different patients. Therefore, it stands to reason that we ought to have plans on hand to deal with the difficult airway, yet many lack such plans.

The bulletproof airway plan requires adequate planning, equipment, training and practice.

Do you have a difficult-airway plan? Does it address all the major problems that might be encountered? Does your arsenal include airway adjuncts that are inexpensive and easily available? Are personnel trained to use them? Do you require continual practice in executing your plan? If not, you're unprepared for the difficult airway.

Equipment should include at least one backup device, such as the dual lumen airway (DLA) or laryngeal mask airway (LMA), some device for percutaneous cricothyrotomy, and equipment and supplies for surgical cricothyrotomy.

The difficult-airway plan should at a minimum require adequate training and practice in endotracheal intubation. Practice in the OR is becoming more difficult because the LMA is being used so extensively, and liability concerns have led many anesthesia groups and hospitals to limit or dispense with training medics in intubation.

If your people can't get enough OR practice, what do you do? Consider a plan that uses one of the adjuncts: DLA, LMA, Proseal LMA or Intubating LMA. In Europe, these devices are now used extensively in the prehospital setting with good results.

The DLA is probably the most popular backup device available today. It is easy to teach, easy to use and has a plethora of research behind it. It is also relatively inex- pensive and disposable. There is no rational argument against training first responders and EMT-Basics to employ it, and many are now using it. A good argument can be made that it is standard of care.

The LMA is being used more and more in prehospital applications. It is simple to use, and, although it is relatively expensive for some services, it can be autoclaved and reused. The common excuse for not using it in prehospital applications is that it doesn't protect the airway from aspiration, but a new version, the ProSeal LMA, has been shown to prevent aspiration. It is actually a double lumen airway in the LMA configuration, which allows blind gastric tube insertion through it.5 In Australia, the original version of the LMA is being used extensively by first responders.6

Your plan should also take into consideration patients with the impossible airway: the short-necked, no-necked, obese patients, or the skinny ones with buck teeth and an anterior airway.

The obese patient is always a challenge, but raising the patient's shoulders with folded blankets or pillows can help bring the airway into alignment.

A simple device called the Eschmann endotracheal tube introducer, commonly called the gum elastic bougie, can greatly help in cases where you can't clearly see the cords. The bougie is a 60 cm, 15 French flexible rod with a "J" bend in the distal end. It has been shown to significantly enhance paramedics' initial success in ET tube placement in difficult patients.7 Anesthesiologists in the U.S. and abroad have used this successfully since its invention in 1948, and more medics in the United States are learning about it.

For patients with facial injuries or tumors that render oral or nasal intubation impossible, you must have a device for cricothyrotomy. There are a number of devices and techniques available, from a simple 14-gauge catheter to commercially available devices. There has been much debate over which of these is best. That issue should be decided by your service, but one of the devices must be available for patients who can't be intubated.

Surgical cricothyrotomy is taught to and employed by many prehospital providers, but some continue to argue that the procedure's risks outweigh its advantages. What is a greater risk than having a patient die if you don't provide an airway? Surgical cricothyrotomy is a last resort, but when it's the only thing between your patient and certain death, there's not much choice. The key is proper training.

Good information on this and the other devices described here can be found on the Internet, but no plan or equipment is good without the right training and practice in its use. Training only begins when the operator knows how to employ the device. The real training must consist of practice and rehearsal for all types of situations.

A professional football team that was only concerned with knowing how to catch and throw the football would be laughed out of the stadium. A professional team uses alternative strategies, offensive and defensive plays, and all are practiced until they can be executed smoothly and almost automatically. The same is true in our "game."

Unless you practice your airway "plays," you're not prepared for the difficult airway. This means repeated scenario practice. It means actual hands-on practice in getting ready to perform pharmacologically assisted intubation (PAI) by drawing up drugs, laying them out in sequence, and arranging your failsafe equipment, suction and other devices so they're ready to go without having to dig through a bag or rummage through a cabinet to find them. Until you can do all this smoothly, you have no business doing rapid sequence intubation (RSI) or PAI on a patient.

A Note on Standard of Care

What does all of this have to do with standard of care? Everything.

Standard of care, which is greatly misunderstood by medical professionals, is what a judge or jury decides it is. Dueling experts testify about their perceptions of it, but it's a jury of lay people who decide what it really is, based upon what the experts tell them under oath.

People who are well acquainted with airway issues are the ones who become expert witnesses. It should be clear that those experts will testify that all of the readily available and affordable devices ought to be available for use.

I often hear the argument that it's just not practical to carry devices and train for procedures you might seldom or never use. That's a little like saying you don't need life insurance because your chances of dying this year are slim, or you don't need medical insurance because you're hardly ever sick. Why should airline pilots practice for wheels-up landings when that almost never happens?

There is a lot more to standard of care than being able to perform procedures on manikins. Standard of care includes every aspect of care, including ongoing training and preparation.

Summing Up

Avoid the three cardinal sins of airway management. Here are some ideas that should help:

• Think about what good airway management really is. Make a difficult-airway management plan.
• Practice ventilation with the BVM until you can do it efficiently and unfailingly. Use a partner to help you ventilate whenever possible.
• Learn as many "tricks" as possible to help you intubate. If your service won't buy a gum elastic bougie, buy one yourself. Take advantage of any and all devices that are simple and affordable to aid you in getting the tube placed the first time, then making sure it stays there.
• Learn to document airway management and practice it. If you can document a procedure correctly, you understand how to do it, and good documentation will induce good practice.
• Rehearse your plan again and again. Practice every complication and variation you can think of with your partners.
• Leave your macho attitude behind when you go to work. If the first thing you try on a difficult airway isn't working, do something else. Albert Einstein is quoted as saying, "Insanity is doing the same thing over and over again and expecting different results." Every dog and pony has one trick, but the one who has the most tricks wins the show.

It's worth improving your airway management skills. If your patient can't breathe, nothing else matters.

References

1. Rich JM. Street Level Airway Management (SLAM). The Airway Education Research Foundation, Dallas, TX.
2. American Heart Association, ACLS Principles and Practice, Chapter 8: p. 150, 2003.
3. Yap SJ, Morris RW, Pybus DA. Alterations in endotracheal tube position during general anaesthesia. Anaesth Intensive Care 22(5):586-588, Oct 1994.
4. American Heart Association, ACLS Principles and Practice, Chapter 8: p. 169, 2003.
5. Keller C, Brimacombe J, Kleinsasser A, Loeckinger A. Does the ProSeal laryngeal mask airway prevent aspiration of regurgitated fluid? Anesth Analg 2001 Oct93(4):1082.
6. www.firstresponseaustralia.com.au/newsletters/fr_sept03.pdf
7. Pitt K, Woollard M. Should paramedics bougie on down? Prehospital Immediate Care 4:68-70, 2000.