Paramedics Need To Consistently Reevaluate Their Patient’s Airway To Ensure Patency

Posted on 10th Feb 2020

Paramedics throughout the country perform life-savings skills on a daily basis. Many
people that would have previously died from their illness or injury are still alive due to the skill
of talented Emergency Medical Services personnel such as paramedics. One particular skill set
used by paramedics in the pre-hospital setting is endotracheal intubation. Endotracheal
intubation involves placing a tube into a patient’s mouth or nose, down through the vocal cords
and into the trachea to provide a pathway to deliver oxygen to a patient that is not breathing.
Once the tube is placed into the patient’s trachea a series of checks need to be used to
ensure the tube is truly in the trachea and not accidentally placed into the esophagus.
Misplacement or displacement of the endotracheal tube into the esophagus can be fatal if it is
not quickly recognized, removed and properly placed into the trachea. The misplaced tube into
the esophagus will result in the patient not being properly ventilated, thus denying them
potentially life saving oxygen during a recesscitation effort by EMS personnel.
Paramedics have been trained to assess proper tube placement using the following
techniques:
- during the intubation process, directly visualizing the tube pass through the vocal cords
- using a stethoscope to auscultate the patient’s lung fields to listen for the sound of air
entering the lungs during the use of a bag-valve-mask device to deliver oxygen to the patient
- the use of a colorimetric device on the endotracheal tube to detect the exhalation of carbon
dioxide (CO2) via the endotracheal tube which indicates the tube is in the trachea.
- the use of an end-tidal CO2 device (ETCO2) connected to a cardiac monitor capable of
monitoring end-tidal CO2. This is also called quantitative wave form capnography.
It is important to note that a combination of the tube placement tools must be used to
ensure proper tube placement, the use of visualization alone is not enough to ensure proper
tube placement. The gold-standard in determining proper endotracheal tube placement is the
use of waveform capnography. In addition to monitoring ET tube placement, quantitative
waveform capnography allows healthcare personnel to monitor CPR quality, optimize chest
compressions, and detect return of spontaneous circulation during chest compressions or
when a rhythm check reveals and organize rhythm. The American Heart Association 1
continues, providers should observe a persistent capnography waveform with ventilation to
confirm and monitor ET tube placement in the field, in the transport vehicle, on arrival at the
hospital, and after any patient transfer to reduce the risk of unrecognized tube
misplacement or displacement.2
Improperly placed endotracheal tube into the esophagus if not recognized can lead to a
lack of oxygen administration to the patient, increased hypoxia and the development of fatal
cardiac arrhythmias. Misplaced endotracheal tubes can contribute to a patient suffering an
anoxic brain injury. Paramedics must ensure proper tube placement with the use of waveform
capnography, this assessment tool has been apart of the American Heart Association’s
Advanced Cardiac Life Support (ACLS) training for more than a decade. Paramedics across the
country are trained in ACLS. The American Heart Association requires renewal of the
certification every two years.
Paramedics in the field need to routinely reassess their patient’s airway following the
placement of an endotracheal tube. Accidental displacement of the tube out of the trachea can
occur during patient movement. The use of waveform capnography by EMS personnel can
help to ensure the endotracheal tube is properly placed within the trachea from the outset as
well as indicate when a patient has a return of spontaneous circulation during a recesscitation
effort. If staffing permits and there are enough paramedics on the scene to treat the patient, a
paramedic should be assigned to solely concentrate on the patient’s airway and ventilation to
ensure the proper care and treatment are delivered to the patient.

1 American Heart Association, ACLS Manual, 2016, pg. 148
2 American Heart Association, ACLS Manual, 2016, pg. 149

Dr. Robert C. Krause