Intubation: Airway Protection

One of the significant clinical skill that is needed by paramedics is the management of airway through intubation. Airway management is a critical basic skill required in doctors, especially in managing patients who are heavily sedated, unconscious, with impaired consciousness, and anaesthetised. Patients that are awake are capable of keeping their airway patent by combining the upper airway muscle tone and several reflexes which keep their trachea and larynx clear of obstructions such as secretions. When patients lose consciousness, both the muscular tone and upper airway reflexes are also lost depending on the impairment degree. When the reflexes of the upper airway are lost, either from active vomiting or passive regurgitated, the person is at stake of losing the airway because of the aspiration of the regurgitated fluids. The trachea or larynx may require to be safeguarded from the consequences of regurgitated, either through inserting a tracheal tube to a point the reflexes of the upper airway return (as it will be discussed in this essay), or via adjusting the patient’s position attempting to make aspiration minimal (Jenkins & Williams, n.d., p. 2).

The tone loss in the upper airway results in the obstruction of the airway, which is usually caused by the tongue falling to a position that is more posterior in the pharynx, hence obstructing the airway. Obstruction can either be a partial obstruction or complete obstruction. Partial obstruction should be addressed to avoid a complete obstruction which results in hypoxia in a short time of 1 to 2 minutes, with bradycardia and then death after a few minutes (Jenkins & Williams, n.d., p. 3). According to Petrou (2017, p. 17), respiratory complications such as those mentioned above are some of the most known emergencies for the paediatricians that need knowledge of pediatric airway physiology knowledge for the required emergent care.

Some of the intubations include the endotracheal intubation, the orotracheal intubation, and tracheal intubation. Endotracheal intubation indications include the following; cardiac arrest; respiratory arrest; patients with imminent with complete obstruction of the airways; the inability of the unconscious patient to safeguard their airways, such as during an overdose, a coma, or ETOH; and the inability of the conscious individual to adequately breathe. One of the endotracheal contraindications is severe airway obstruction or trauma which do not allow safe passage of the endotracheal tube. In such cases, emergency cricothyrotomy is indicated. Another endotracheal contradiction is the Mallampati Classification of class 3 or 4 or anything else that can determine potential difficult airway. A third contradiction is the cervical spine injury whereby the necessity of complete cervical spine immobilisation makes the endotracheal intubation complex (UnityPoint Health, n.d., p. 1). Emergency indications of orotracheal intubation include; respiratory arrests; cardiac arrest; inadequate ventilation or oxygenation; failure to secure airway from aspiration; and anticipated or existing airway obstruction. Orotracheal intubation has very few contraindications, whereby it is somehow contraindicated in a person having partial transection of the trachea as the process can result in a whole tracheal transection and the loss of the airway. In such situations, surgical air management is required. Unstable surgical injury of the spine is not a contraindication. However, strict in-line cervical spine stabilisation must be maintained when intubating (Kabrhel et al., 2007, p. 1).

The intubation process also has some side effects and disadvantages, whereby the different intubation procedures have similar side effects. For instance, endotracheal intubation can result to endobronchial intubation; ETT inserted too far from where it is required; accidental oesophagus intubation; and an endotracheal tube which is mistakenly misplaced or sized, especially in an apneic patient which rapidly leads to hypoxia and fatality. Other side effects of the endotracheal intubation include dentures or broken teeth and oropharyngeal trauma (UnityPoint Health, n.d., p. 1). Orotracheal intubation also has some complications, whereby the most adverse complication is the unrecognised oesophagus intubation which results in hypercapnia, hypoxemia, and death. Laryngoscopy can trigger aspiration and vomiting of gastric contents, leading to pneumonia or pneumonitis. More side effects include bronchospasm, bradycardia, laryngospasm, and apnea owing to stimulation of pharyngeal. Trauma to vocal cords, teeth, lips, and exacerbation of the cervical spine injuries may also take place (Kabrhel et al., 2007, p. 4).

Some scholars have noted down some of their reflections concerning airway management. For instance, according to Caldiroli & Cortellazzi (2013, p. 84), viewed some works and raised some issues such as the increased use of supraglottic airways (SGAs). According to the data viewed, the two scholars state how complex airway management can be improved through following some guidelines of implementation. Other scholars such as McCarthy & Cooper (2018) have had issues understanding how combining some intubation techniques such as the Macintosh Video laryngoscope, the Bonfils Intubation Endoscope, and the difficult airway. Apart from reflections and raised concerns, there are some arguments around the intubation process, whereby some debate whether paramedics should continue the intubation process. One of the reasons for this debate is because some paramedics have performed the intubation process and the patient ends up dying due to some claims of paediatricians having inadequate paramedic education related to airway management as well as negligence from the EMS system’s part (Eckstein, 2010). Many caregivers also argue conversely that the conditions of optimal intubating should be achieved before attempting intubation (Jacobs & Grabinsky, 2014).

Intubation as a way of airway management has had some developments in the recent years. Endotracheal intubation (ETI) continues to be the leading standard for the definitive of managing the airway in the prehospital settings. According to multiple studies, the model which proficient ETI needs rigorous training that is accepted universally and more significant numbers of experience in ETI (Jacobs & Grabinsky, 2014). Additionally, there has been a systematic evaluation of the recent airway devices. Each year, there are new airway devices which enter the market. These devices are designed to facilitate the tracheal intubation or secure the airway (Isono et al., 2011, pp. 4-5). To ensure competence is maintained in the intubation techniques, as mentioned earlier, paediatricians should all be trained and educated. Airway management is a complex skill, hence, critical that the EMS providers are taught proper techniques from the beginning, and they should keep on practising thee taught procedures.

Managing all the airways, including emergency airway, accurately needs a combination of competencies such as the thoughtful clinical making of decisions and excellent motor skills. ETI, for instance, requires a sterile endotracheal tube which should be inserted into the trachea directly. Reliable ETI needs experience and proper technique. The more the paramedic practice the intubation process, the perfect their skills in intubation. Unfortunately, the possibility to practice and acquire such experience is limited as the paramedic providers rarely get the chance to intubate. Additionally, the number of live intubations a paramedic may need in the initial process while training may be minimal and the amount of alternative airway tools which need less training minimises the intubation frequency. Even though training is seldom-used, highly critical skill is very essential to competency maintenance. There are some approaches to ensure that the training offers maximum impacts on acquisition and retention. Additionally, the initial airway education was traditionally using a mixture of group practice and lecture to assist the students in acquiring the needed skill. Such a practice was helpful. However, it limited the skill perfection. It is critical that the initial training is then followed by consistent and repetitive practice and under conditions that are increasingly realistic. For instance, after the students practice with the head used for intubation on the table, it should then be moved to the floor as it is where many of the patients will be positioned. Over time, the trainer should have the manikin on a bed, on a gurney, and anywhere where actual patients will be present. The equipment used should also mimic the situations in the real world. Multiple tubes should be made available to the students so that they can choose the size tube to utilise (Hsieh, 2014).

The students should also master precision. Highly technical processes like endotracheal intubation need substantial practice to achieve the precise performance required. A performance which perfect poses as a baseline for the student to then adapt to an adjusting environment. The student should be allowed to practice individually after being approved by the instructor only; otherwise, the students should practice in pairs, as one observes the other as they attempt. As precision is achieved, one should begin to change the conditions. The instructors should present scenarios where the students have to decide as to whether to do intubation or if the airway can be maintained using the basic life support or the alternative airway tools such as laryngeal mask airway or the supraglottic. Additionally, there has also been an interest in utilising the technology of high-fidelity simulation to help the nurses and physician anaesthetics to get and retain the techniques of airway management. Simulation enables the educator to deliver airway specific to the learning needs of the students. Advanced management of airway is a complex, but a precise task which needs high proficiency levels. Given the minimal frequency of contacts with patients requiring intervention together with high complication costs when the processes fail, its crucial that the providers of EMS learn proper techniques from the beginning and continue practising them (Hsieh, 2014).

The protocols of intubation are different in institutions, vary on a case to case situation, with the anesthesiologists that are routinely involved, as well as not at all. Principles and goals for the process are universal. However, the patient undergoing the procedure should be kept safe, as comfortable as possible, and minimally stressed. While the individual patient necessities may be different, significant experience with the emergency management of airway recommends that the general method with the highest rate of success is fast sequence induction of anaesthesia offered on a deep level and complete relaxation of the muscles, then followed by orotracheal intubation through direct laryngoscopy. Primary to the success of this method is an acknowledgement by all those participating in the plan for the management of the airway. This may directly arise from the guide that is nationally published, such as the Difficult Airway Algorithm of the American Society of Anesthesiologists. It may also be locally modified to reflect the patient population or the particular environment (Rabinovici et al., 2016, p. 520).

The previous studies suggest enhanced patient outcomes for providers who do high volumes of challenging medical processes such as intubation. There have been several advancements that have been made in the emergency airway management, and continued research is also recommended to address further enhancing identification of high-risk patients that are critically ill. The research will also assist in the evaluation of optimal tools, the selection of drugs, and optimising devices to enhance the first attempts success as well as minimise the complications. Studies aiding in the research of airway management have been concluded, for instance, Mosier and his colleagues published a curriculum of airway management of three years experience which was inclusive of intensive programs based on simulations with gradually increasing complexity concentrating on the identification of as well as the approach to the potentially complex airway. Mosier’s curriculum enhanced the odds of the first trials success and minimised complications in the intensive care unit/ this was with an overall first trial success of greater than 80 per cent and almost 90 per cent when a video laryngoscope was utilised (Natt et al., 2016).