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Advanced Airways: Best Practices

One of the differences between BLS and ACLS is the introduction of the advanced airway, but this technique is not without its controversies. Although many different types of healthcare providers can take ACLS, only a few (i.e. doctors, respiratory therapists) are actually trained in endotracheal intubation. In some states, only certain providers can intubate patients, and the ACLS class does not teach you how to perform this technique. However, understanding how to intubate and the equipment needed is important if you are called upon to assist in the intubation process.

In the field, performing an intubation is more difficult and can be dangerous. Futhermore, it often doesn’t provide superior oxygenation to simple bag valve mask airway management. Nurses, EMTs, and other professionals trained in ACLS may not have the skills or the scope of practice to perform this skill, and that is why learning the other methods of airway management is so important. Although bag valve mask ventilation is considered a BLS technique, it is still the best way to manage a patient’s airway, especially out of hospital. In emergency rooms, ICUs and hospital wards, doctors are generally on hand to perform intubation, but no one should attempt this technique without thorough training and licensure by the state.

Bag Valve Mask Superior to Advanced Airways

When in the field, the bag valve mask technique of ventilation is often more effective than attempting to intubate a patient. First, inserting an ET tube usually requires a great deal of skill and takes a considerable amount of time. As time is of the essence during an arrest or code, intubation can take away from other activities that are equally, or even more, important. Since arrests don’t happen every day (unless you work in a very busy level one trauma center!), many lower tier professionals don’t have the necessary experience to insert an ET tube. This means that the likelihood of complications related to insertion of the ET tube is much higher. In fact, inserting a tube is often fraught with complications, even for experienced practitioners.

However, with the bag valve mask, the airway can be maintained and rescue breaths can be provided effectively. Even in situations where insertion of a tube would not take a great deal of time, it is better to use a bag valve mask if ventilations are being provided effectively to ensure that no complications arise from a misplaced tube. In hospital, the ET tube should be placed by a physician, but even then it should only be attempted if there is no other choice. If the patient begins to breathe spontaneously, an ET tube will not be necessary. In the end, though, only doctors with a great deal of experience, such as anesthesiologists and emergency room physicians, should attempt to insert an ET tube.

Subglottal Intubation

Some of the newer methods to intubate patients involve using devices that don’t involve intubating the trachea. There are several types of devices, and they all revolve around the subglottal region. This means that they are inserted to or just beyond the back of the throat, but they do not descend into the lungs. They are easier to place than ET tubes, and they have fewer risks associated with insertion. Again, training with these devices is key. One such device is the Combitube, which blocks off the esophagus and directs air into the trachea. This causes fewer instances of aspiration, more reliable ventilation during ACLS, and mechanical isolation of the airway. It is far easier to train to use a Combitube correctly, and it doesn’t have the risks that inserting an ET tube would pose. However, you may find that attempting to insert a Combitube is a waste of precious time when transporting the patient to the hospital. In the hospital, the doctors there are more likely to intubate, and a Combitube would only be used if intubation with an ET tube was unsuccessful.

One such device is the Combitube, which blocks off the esophagus and directs air into the trachea. This causes fewer instances of aspiration, more reliable ventilation during ACLS, and mechanical isolation of the airway. It is far easier to train to use a Combitube correctly, and it doesn’t have the risks that inserting an ET tube would pose. However, you may find that attempting to insert a Combitube is a waste of precious time when transporting the patient to the hospital. In the hospital, the doctors there are more likely to intubate, and a Combitube would only be used if intubation with an ET tube was unsuccessful.

Endotracheal Intubation

Endotracheal intubation is the Everest of emergency procedures. When it is performed by inexperienced practitioners, it can lead to trauma of the oropharynx, intubation of the esophagus, and injury to the lungs themselves. While in hospital, the placement of the tube can be checked by several methods, such as x-ray, but many of these methods of verifying placement are not available in the field. This may mean that you are giving breaths that are not helping the patient and you are, in fact, hurting them. It is much easier to use the bag valve mask in these situations.

If an ET tube is needed, then a practitioner must be absolutely certain that they can handle the procedure. It takes a lot of practice to get the hang of inserting an ET tube. Like IVs, the more a person practices, the better they will perform this skill. If you are a paramedic, you may want to shadow in the OR and assist the anesthesiologist in intubating patients for surgical procedures. If you find yourself needing to insert an ET tube in the field, you should not hesitate to use one if you are trained, but you should also keep in mind the risks to your patient. Only with honest assessment of your skills will you be able to make the right choice for your patient.

Source

http://circ.ahajournals.org/content/112/24_suppl/IV-51.full